Provider Demographics
NPI:1548245012
Name:SCHWAB, SHANNON J (DO)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:J
Last Name:SCHWAB
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:J
Other - Last Name:KOWAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:304 SAVOY ST
Mailing Address - Street 2:
Mailing Address - City:BULLARD
Mailing Address - State:TX
Mailing Address - Zip Code:75757-5497
Mailing Address - Country:US
Mailing Address - Phone:507-380-4784
Mailing Address - Fax:
Practice Address - Street 1:8288 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703
Practice Address - Country:US
Practice Address - Phone:903-606-7060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN40982207Q00000X
TXQ5925207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX350893901Medicaid
TX443579YMAFOtherMEDICARE ID