Provider Demographics
NPI:1538107511
Name:WIPF, SHANNON (MD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:WIPF
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 W PERSIMMON ST
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72756-3383
Mailing Address - Country:US
Mailing Address - Phone:479-636-7192
Mailing Address - Fax:
Practice Address - Street 1:1615 W PERSIMMON ST
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-3359
Practice Address - Country:US
Practice Address - Phone:479-636-7192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE3256207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR146562001Medicaid
ARG17007Medicare UPIN
AR146562001Medicaid