1548514615 NPI number — LISA SHANNON D.O.

Table of content: LISA SHANNON D.O. (NPI 1548514615)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548514615 NPI number — LISA SHANNON D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHANNON
Provider First Name:
LISA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548514615
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
367 S. GULPH RD
Provider Second Line Business Mailing Address:
ATT IPM CREDENTIALING
Provider Business Mailing Address City Name:
KING OF PRUSSIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19406-3121
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
775-356-9393
Provider Business Mailing Address Fax Number:
775-356-5590

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5225 MANATEE AVE W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRADENTON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34209-3742
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-708-8081
Provider Business Practice Location Address Fax Number:
941-708-8085
Provider Enumeration Date:
10/29/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  402902 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 011944000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: HU312Z . This is a "MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 011944000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".