Provider Demographics
NPI:1336116821
Name:GULLEY, SHANNON (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
Last Name:GULLEY
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:PO BOX 75032
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60675-5032
Mailing Address - Country:US
Mailing Address - Phone:907-746-1520
Mailing Address - Fax:907-746-1521
Practice Address - Street 1:425 E DAHLIA AVE STE J
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-6463
Practice Address - Country:US
Practice Address - Phone:907-746-1520
Practice Address - Fax:907-746-1521
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKMEDS8191208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0157403Medicaid
MT000085542Medicare PIN
H22698Medicare UPIN