Provider Demographics
NPI:1407067739
Name:SHANNON, ANGELA B (MD)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:B
Last Name:SHANNON
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:1679 OLD FANNIN RD STE E
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-8101
Mailing Address - Country:US
Mailing Address - Phone:601-398-1949
Mailing Address - Fax:769-216-3044
Practice Address - Street 1:1679 OLD FANNIN RD STE E
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-8101
Practice Address - Country:US
Practice Address - Phone:601-398-1949
Practice Address - Fax:769-216-3044
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS220092080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05307227Medicaid
MS302I708100Medicare PIN