Provider Demographics
NPI:1144204405
Name:WEBB, SHANNON CLAYE (MD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:CLAYE
Last Name:WEBB
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 1:5818 VILLA LORENZO DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-5415
Mailing Address - Country:US
Mailing Address - Phone:864-494-2134
Mailing Address - Fax:
Practice Address - Street 1:722 S WAHSATCH AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-4035
Practice Address - Country:US
Practice Address - Phone:719-632-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22749207Q00000X
MDD0091535207Q00000X
CODR0071691207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC227490Medicaid
SC227490Medicaid