Provider Demographics
NPI:1508628777
Name:SHANNON, ARDIS CHRISTOPHER
Entity Type:Individual
Prefix:
First Name:ARDIS
Middle Name:CHRISTOPHER
Last Name:SHANNON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4522 MARLIN AVENUE, SUFFOLK, VA, USA
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-2377
Mailing Address - Country:US
Mailing Address - Phone:757-641-1876
Mailing Address - Fax:
Practice Address - Street 1:4522 MARLIN AVE
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-2377
Practice Address - Country:US
Practice Address - Phone:757-641-1876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-24
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS243944436343800000X, 343900000X, 172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No343800000XTransportation ServicesSecured Medical Transport (VAN)
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)