Provider Demographics
NPI:1306838990
Name:SHANNAHAN, TIMOTHY EVANS (DC)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:EVANS
Last Name:SHANNAHAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1764 SAN DIEGO AVE STE 140
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-1987
Mailing Address - Country:US
Mailing Address - Phone:619-543-9999
Mailing Address - Fax:
Practice Address - Street 1:1764 SAN DIEGO AVE STE 140
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-1987
Practice Address - Country:US
Practice Address - Phone:619-543-9999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24900111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC24900Medicare ID - Type Unspecified