Provider Demographics
NPI:1437236163
Name:MCCUNE, SHANNON LEE (MD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LEE
Last Name:MCCUNE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:LEE
Other - Last Name:FINK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2850 TELEGRAPH AVE STE 130
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-1159
Mailing Address - Country:US
Mailing Address - Phone:510-204-8110
Mailing Address - Fax:510-843-0804
Practice Address - Street 1:2850 TELEGRAPH AVE STE 130
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-1159
Practice Address - Country:US
Practice Address - Phone:510-204-8110
Practice Address - Fax:510-843-0804
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA65481207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG90701Medicare UPIN