Provider Demographics
NPI:1417124538
Name:HANSEN, SHANNON GABRIELLE (MD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:GABRIELLE
Last Name:HANSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:GABRIELLE
Other - Last Name:BRADLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 5299
Mailing Address - Street 2:MS: 820-5-PCO
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98415-0299
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:315 MARTIN LUTHER KING JR WAY
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4234
Practice Address - Country:US
Practice Address - Phone:253-403-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-08
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN51866207Q00000X
WAMD60293423207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00767187OtherMEDICARE RAILROAD
01-37427OtherMEDICA
MN1417124538Medicaid
MN1417124538OtherBCBS
1417124538OtherGROUP HEALTH
MN1417124538Medicaid