Provider Demographics
NPI:1023016789
Name:CARR, SHANNON (MD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:CARR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 WATER ST
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-6559
Mailing Address - Country:US
Mailing Address - Phone:207-873-9841
Mailing Address - Fax:207-873-9845
Practice Address - Street 1:2211 LOMAS BLVD NE
Practice Address - Street 2:4TH FLOOR AMBULATORY CARE CTR
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-2719
Practice Address - Country:US
Practice Address - Phone:505-272-2245
Practice Address - Fax:505-272-1109
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME016521207V00000X
NMMD2012-0010207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME416350099Medicaid
MEI22321Medicare UPIN
MEME1064Medicare PIN