Provider Demographics
NPI:1205813326
Name:TARRER, SHANNAN M (MD)
Entity Type:Individual
Prefix:
First Name:SHANNAN
Middle Name:M
Last Name:TARRER
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 1:820 PRUDENTIAL DR STE 713
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-8209
Mailing Address - Country:US
Mailing Address - Phone:904-396-5682
Mailing Address - Fax:904-346-0864
Practice Address - Street 1:800 PRUDENTIAL DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8202
Practice Address - Country:US
Practice Address - Phone:904-396-5682
Practice Address - Fax:904-346-0864
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-29
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME106553207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002096200Medicaid
NY1326Q1OtherBLUECROSS BLUESHIELD
P00206266Medicare PIN
H99613Medicare UPIN
NY02393337Medicaid