Provider Demographics
NPI:1093154742
Name:O'CONNOR, SHANNON (MPT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:O'CONNOR
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 24573
Mailing Address - Street 2:
Mailing Address - City:BARRIGADA
Mailing Address - State:GU
Mailing Address - Zip Code:96921-4573
Mailing Address - Country:US
Mailing Address - Phone:671-788-7573
Mailing Address - Fax:
Practice Address - Street 1:C-1 SANTOS WAY
Practice Address - Street 2:PALM SEAS CONDO
Practice Address - City:TUMON
Practice Address - State:GU
Practice Address - Zip Code:96911
Practice Address - Country:US
Practice Address - Phone:671-788-7573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-17
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUPT-104225100000X
GAPT008218225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist