1053419796 NPI number — PATRICIA JEAN SHANNON PHD, LP

Table of content: DR. JACOB M STANFIELD M.D. (NPI 1164740403)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053419796 NPI number — PATRICIA JEAN SHANNON PHD, LP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHANNON
Provider First Name:
PATRICIA
Provider Middle Name:
JEAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHD, LP
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:
1053419796
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/29/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3108 HENNEPIN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55408-2619
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-825-4407
Provider Business Mailing Address Fax Number:
612-825-0768

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3133 HENNEPIN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55408-2620
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-834-7780
Provider Business Practice Location Address Fax Number:
612-624-3744
Provider Enumeration Date:
09/20/2006

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: 103T00000X , with the licence number:  4075 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 921813100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".