Provider Demographics
NPI:1376912618
Name:REYNOLDS, SHANNON (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
Last Name:REYNOLDS
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 649
Mailing Address - Street 2:
Mailing Address - City:FORT DEFIANCE
Mailing Address - State:AZ
Mailing Address - Zip Code:86504-0649
Mailing Address - Country:US
Mailing Address - Phone:928-729-8600
Mailing Address - Fax:
Practice Address - Street 1:CORNER OF ROUTE N12 AND N7
Practice Address - Street 2:
Practice Address - City:FORT DEFIANCE
Practice Address - State:AZ
Practice Address - Zip Code:86504
Practice Address - Country:US
Practice Address - Phone:928-729-8132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-16
Last Update Date:2023-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA135859207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine