Provider Demographics
NPI:1003818253
Name:O'HAGAN, SHANNON (PT)
Entity Type:Individual
Prefix:MISS
First Name:SHANNON
Middle Name:
Last Name:O'HAGAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4763 LAMONT ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-3420
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1920 CORDELL CT
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-0900
Practice Address - Country:US
Practice Address - Phone:619-258-7497
Practice Address - Fax:619-258-7260
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 27227225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT272270OtherBLUE SHIELD
CAOPT272270OtherBLUE SHIELD
CAW17072AMedicare ID - Type UnspecifiedMEDICARE GROUP NUMBER