Provider Demographics
NPI:1053464404
Name:HEDSTROM BARNES, SHANNON (ABOC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:HEDSTROM BARNES
Suffix:
Gender:F
Credentials:ABOC
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:HEDSTROM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ABOC
Mailing Address - Street 1:PO BOX 35100
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59107-5100
Mailing Address - Country:US
Mailing Address - Phone:406-238-2500
Mailing Address - Fax:
Practice Address - Street 1:2825 8TH AVE N
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59101-0909
Practice Address - Country:US
Practice Address - Phone:406-238-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0551072Medicaid
MT0551072Medicaid