Provider Demographics
NPI:1013405828
Name:SHANNON, MEAGHAN
Entity Type:Individual
Prefix:
First Name:MEAGHAN
Middle Name:
Last Name:SHANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 STUDEMONT ST APT 3437
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77007-4968
Mailing Address - Country:US
Mailing Address - Phone:813-385-4252
Mailing Address - Fax:
Practice Address - Street 1:16811 SOUTHWEST FWY
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479-4728
Practice Address - Country:US
Practice Address - Phone:281-609-7547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-26
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL43792255A2300X
TXAT69092255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000019902OtherBOARD OF CERTIFICATION FOR THE ATHLETIC TRAINER
FLAL4379OtherLICENSED ATHLETIC TRAINER
TXAT6909OtherLICENSED ATHLETIC TRAINER