Provider Demographics
NPI:1205843596
Name:SHANNON, SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:SHANNON
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 1:7603 COLLAND DR
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-6929
Mailing Address - Country:US
Mailing Address - Phone:970-663-2686
Mailing Address - Fax:970-663-1226
Practice Address - Street 1:7603 COLLAND DR
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-6929
Practice Address - Country:US
Practice Address - Phone:970-663-2686
Practice Address - Fax:970-663-1226
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO310902084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO31090OtherMD
3573OtherAM BOARD OF PSYH
AS2387214OtherDEA
AS2387214OtherDEA