Provider Demographics
NPI:1346228996
Name:SHANNON, MOIRA (MD)
Entity Type:Individual
Prefix:
First Name:MOIRA
Middle Name:
Last Name:SHANNON
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 1:2202 N FORBES BLVD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85745-1412
Mailing Address - Country:US
Mailing Address - Phone:520-777-2288
Mailing Address - Fax:520-777-2290
Practice Address - Street 1:2500 N SILVERBELL RD
Practice Address - Street 2:SUITE 100
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85745-7062
Practice Address - Country:US
Practice Address - Phone:520-777-2288
Practice Address - Fax:520-777-2290
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ128202083X0100X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ246521Medicaid
AZ246521Medicaid
AZD37633Medicare UPIN