Provider Demographics
NPI:1336278894
Name:BOLON, SHANNON K (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:K
Last Name:BOLON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:K
Other - Last Name:SWICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:UNIV OF CINCINNATI DEPART OF FAMILY MEDICINE
Mailing Address - Street 2:P.O. BOX 670582
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45267-0001
Mailing Address - Country:US
Mailing Address - Phone:513-558-1430
Mailing Address - Fax:513-558-3266
Practice Address - Street 1:301 11TH ST
Practice Address - Street 2:SUITE C
Practice Address - City:NEW KENSINGTON
Practice Address - State:PA
Practice Address - Zip Code:15068-6179
Practice Address - Country:US
Practice Address - Phone:724-334-3640
Practice Address - Fax:724-334-3644
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD430353207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine