Provider Demographics
NPI:1164627279
Name:WRONKOWICZ, SHANNON MARIE (MD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:WRONKOWICZ
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 1:628 MEADOWCHASE LN
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615-4244
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2213 CHERRY ST
Practice Address - Street 2:6TH FLOOR
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43608-2603
Practice Address - Country:US
Practice Address - Phone:419-251-4993
Practice Address - Fax:419-251-5330
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35089683208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2758903Medicaid