Provider Demographics
NPI:1184829921
Name:ETTER, SHANNON MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:MARIE
Last Name:ETTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SHANNON
Other - Middle Name:MARIE
Other - Last Name:CAPP
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1 BOONE RD
Mailing Address - Street 2:NAVAL HOSPITAL BREMERTON
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98312-1894
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9455 CLAIREMONT MESA BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1297
Practice Address - Country:US
Practice Address - Phone:858-266-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-20
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101244203207V00000X
CAC181763207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD0000Medicare UPIN