Provider Demographics
NPI:1427192459
Name:SHEVOCK-JOHNSON, SHANNON L (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:L
Last Name:SHEVOCK-JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SHANNON
Other - Middle Name:L
Other - Last Name:SHEVOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3396 VICTORIA ST N
Mailing Address - Street 2:
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-3862
Mailing Address - Country:US
Mailing Address - Phone:202-680-2260
Mailing Address - Fax:
Practice Address - Street 1:2925 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-1321
Practice Address - Country:US
Practice Address - Phone:612-262-3738
Practice Address - Fax:612-262-4258
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA232775207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine