Individual
SHANE BANNON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
1 CONVENTION AVE, PHILADELPHIA, PA 19104-4311
(800) 789-7366
Mailing address
285 BIRCH DR, LAFAYETTE HILL, PA 19444-2103
Taxonomy
Speciality
Code
Description
License number
State
363LA2100X
Acute Care Nurse Practitioner
Primary
SP024901
PA
Other
Enumeration date
11/24/2021
Last updated
11/24/2021
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