Provider Demographics
NPI:1033227483
Name:SHANNON, MARYELLEN KATHRYN (MD)
Entity Type:Individual
Prefix:MS
First Name:MARYELLEN
Middle Name:KATHRYN
Last Name:SHANNON
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 1:6 HUGHES
Mailing Address - Street 2:STE 100
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-2059
Mailing Address - Country:US
Mailing Address - Phone:949-680-1880
Mailing Address - Fax:949-680-1881
Practice Address - Street 1:6 HUGHES
Practice Address - Street 2:STE 100
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-2059
Practice Address - Country:US
Practice Address - Phone:949-680-1880
Practice Address - Fax:949-680-1881
Is Sole Proprietor?:No
Enumeration Date:2006-08-27
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ19717207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ04886Medicaid
16WCKFB01Medicare ID - Type Unspecified
AZ04886Medicaid