Provider Demographics
NPI:1568528990
Name:BONNESS, SHANNON (MD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BONNESS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:SHANNON
Other - Last Name:BONNESS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4108 DEL REY AVE
Mailing Address - Street 2:APT. 511
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-4804
Mailing Address - Country:US
Mailing Address - Phone:402-578-8812
Mailing Address - Fax:
Practice Address - Street 1:4108 DEL REY AVE
Practice Address - Street 2:APT. 511
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-4804
Practice Address - Country:US
Practice Address - Phone:402-578-8812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC55574207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NEG19855Medicare UPIN