Provider Demographics
NPI:1467515536
Name:MULDER MICHAELSON, SHANNON MIRI (MD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MIRI
Last Name:MULDER MICHAELSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:MIRI
Other - Last Name:MULDER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:25539 HURON ST
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3722
Mailing Address - Country:US
Mailing Address - Phone:909-796-4996
Mailing Address - Fax:909-796-4996
Practice Address - Street 1:11234 ANDERSON ST
Practice Address - Street 2:RM 2532
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-2804
Practice Address - Country:US
Practice Address - Phone:909-558-4475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2009-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG53813207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
A52604Medicare UPIN