Provider Demographics
NPI:1164635520
Name:JOHNSON, SHANNON PATRICK (IDC)
Entity Type:Individual
Prefix:MR
First Name:SHANNON
Middle Name:PATRICK
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1096 VALENCIA CT
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-6789
Mailing Address - Country:US
Mailing Address - Phone:757-301-8921
Mailing Address - Fax:
Practice Address - Street 1:1004 HERMITAGE RD
Practice Address - Street 2:BLDG 2052
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23521-5000
Practice Address - Country:US
Practice Address - Phone:757-462-3178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman