Provider Demographics
NPI:1376799817
Name:MACLEAN, SHANNON (DO)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:MACLEAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050A 2ND ST SE
Mailing Address - Street 2:
Mailing Address - City:KIRTLAND AFB
Mailing Address - State:NM
Mailing Address - Zip Code:87117-5522
Mailing Address - Country:US
Mailing Address - Phone:505-853-7992
Mailing Address - Fax:
Practice Address - Street 1:2050A 2ND ST SE
Practice Address - Street 2:
Practice Address - City:KIRTLAND AFB
Practice Address - State:NM
Practice Address - Zip Code:87117-1110
Practice Address - Country:US
Practice Address - Phone:253-968-1110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-15
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0051993208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice