1225111602 NPI number — SHANNON R GIBBONS MA, FAAA

Table of content: SHANNON R GIBBONS MA, FAAA (NPI 1225111602)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225111602 NPI number — SHANNON R GIBBONS MA, FAAA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GIBBONS
Provider First Name:
SHANNON
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, FAAA
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:
1225111602
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8800 SE SUNNYSIDE RD STE 300N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLACKAMAS
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97015-5703
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-286-2999
Provider Business Mailing Address Fax Number:
512-607-4893

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27 HARTFORD TURNPIKE
Provider Second Line Business Practice Location Address:
RT#83
Provider Business Practice Location Address City Name:
VERNON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06066
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-646-7900
Provider Business Practice Location Address Fax Number:
860-646-7792
Provider Enumeration Date:
10/23/2006

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: 237700000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 237600000X , with the licence number: 000356 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: D400031083 . This is a "MEDICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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