Provider Demographics
NPI:1306819479
Name:ALLEN-GRYZWA, SHANNON PHEADRA (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:PHEADRA
Last Name:ALLEN-GRYZWA
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 1:240 MAPLE AVE
Mailing Address - Street 2:PROHEALTH CARE MEDICAL ASSOCIATES INC.
Mailing Address - City:MUKWONAGO
Mailing Address - State:WI
Mailing Address - Zip Code:53149-8475
Mailing Address - Country:US
Mailing Address - Phone:262-928-1900
Mailing Address - Fax:
Practice Address - Street 1:PREMISE HEALTHCARE MILLER HEALTH & FITNESS
Practice Address - Street 2:4400 W. STATE ST.
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208
Practice Address - Country:US
Practice Address - Phone:262-928-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI40073207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32639500Medicaid
WIH12336Medicare UPIN
WI32639500Medicaid
683750614Medicare PIN