Provider Demographics
NPI:1235322827
Name:FARAG, SHANNON DAYE (MD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:DAYE
Last Name:FARAG
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 1:5000 COX RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-9263
Mailing Address - Country:US
Mailing Address - Phone:804-968-5700
Mailing Address - Fax:804-217-7991
Practice Address - Street 1:60 PROSPERITY LN
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22556-4605
Practice Address - Country:US
Practice Address - Phone:540-658-2811
Practice Address - Fax:540-658-2812
Is Sole Proprietor?:No
Enumeration Date:2007-08-27
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101248608207Q00000X
CAA95602207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVV0837A - C03895Medicare PIN