Provider Demographics
NPI:1386631935
Name:SHANNON, AMIE B (MD)
Entity Type:Individual
Prefix:
First Name:AMIE
Middle Name:B
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 1:5326 O'DONOVAN DRIVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-9153
Mailing Address - Country:US
Mailing Address - Phone:225-769-7546
Mailing Address - Fax:225-769-0471
Practice Address - Street 1:5326 O'DONOVAN DRIVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-9153
Practice Address - Country:US
Practice Address - Phone:225-769-7546
Practice Address - Fax:225-769-0471
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA200217207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1628093Medicaid
H85176Medicare UPIN
4J797DD21Medicare PIN
LA4J797B487Medicare PIN