| Entity Name: | LISA SHANNON DO, PA |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 09 Dec 2019 (5 years ago) |
| Document Number: | P19000092885 |
| FEI/EIN Number | 84-3726162 |
| Address: | 2901 US 301 N, ellenton, FL, 34222, US |
| Mail Address: | 250 2ND ST EAST, 3B, BRADENTON, FL, 34208, US |
| ZIP code: | 34222 |
| County: | Manatee |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1639718836 | 2020-01-06 | 2023-09-06 | 250 2ND ST E STE 3B, BRADENTON, FL, 342081027, US | 250 2ND ST E STE 3B, BRADENTON, FL, 342081027, US | |||||||||||||||||||
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| Phone | +1 941-746-4151 |
Authorized person
| Name | DR. LISA SHANNON |
| Role | PHYSICIAN |
| Phone | 9417464151 |
Taxonomy
| Taxonomy Code | 261QP2300X - Primary Care Clinic/Center |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 011944000 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| SHANNON LISA | Agent | 250 2ND ST EAST, BRADENTON, FL, 34208 |
| Name | Role | Address |
|---|---|---|
| SHANNON LISA | President | 250 2ND ST EAST, BRADENTON, FL, 34208 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF MAILING ADDRESS | 2025-02-01 | 2901 US 301 N, ellenton, FL 34222 | No data |
| CHANGE OF MAILING ADDRESS | 2024-02-01 | 2901 US 301 N, ellenton, FL 34222 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2020-09-01 | 2901 US 301 N, ellenton, FL 34222 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-02-13 |
| ANNUAL REPORT | 2023-02-14 |
| ANNUAL REPORT | 2022-03-02 |
| ANNUAL REPORT | 2021-02-17 |
| ANNUAL REPORT | 2020-01-20 |
| Domestic Profit | 2019-12-09 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
