Provider Demographics
NPI:1508801622
Name:FOGARTY, SHANNON M (NP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:FOGARTY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:M
Other - Last Name:WHITAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1055 N MAYFAIR RD
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3436
Mailing Address - Country:US
Mailing Address - Phone:414-479-2300
Mailing Address - Fax:
Practice Address - Street 1:1055 N MAYFAIR RD
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226
Practice Address - Country:US
Practice Address - Phone:414-479-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1545-033363L00000X
WI120438-030363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI500014946OtherMEDICARE RAILROAD
WI43917700Medicaid
WI0054-32280Medicare ID - Type Unspecified
WI43917700Medicaid
WI0081-68655Medicare ID - Type Unspecified
WI0053-32350Medicare ID - Type Unspecified
WI0081-01400Medicare ID - Type Unspecified