Provider Demographics
NPI:1285203893
Name:GAYLES, SHANNON K
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:K
Last Name:GAYLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10225 WORTHAM BLVD APT 15203
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77065-3045
Mailing Address - Country:US
Mailing Address - Phone:281-942-6430
Mailing Address - Fax:
Practice Address - Street 1:10225 WORTHAM BLVD
Practice Address - Street 2:15203
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77065
Practice Address - Country:US
Practice Address - Phone:281-942-6430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-18
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246R00000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX246R00000XMedicaid