Provider Demographics
NPI:1134107105
Name:SHANNON, WENDELL K (MD)
Entity Type:Individual
Prefix:
First Name:WENDELL
Middle Name:K
Last Name:SHANNON
Suffix:
Gender:M
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:PO BOX 1104
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:AL
Mailing Address - Zip Code:35612-1104
Mailing Address - Country:US
Mailing Address - Phone:256-216-9777
Mailing Address - Fax:256-216-9776
Practice Address - Street 1:1600 W HOBBS ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:AL
Practice Address - Zip Code:35611-2333
Practice Address - Country:US
Practice Address - Phone:256-216-9777
Practice Address - Fax:256-216-9776
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AL7268207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALC72794Medicare UPIN