Provider Demographics
NPI:1578534269
Name:PARKOS, SHANNON JO (MD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:JO
Last Name:PARKOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:JO
Other - Last Name:REEDY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8100 34TH AVE S
Mailing Address - Street 2:MS 21110Q
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1672
Mailing Address - Country:US
Mailing Address - Phone:952-883-5790
Mailing Address - Fax:952-883-5395
Practice Address - Street 1:15290 PENNOCK LN
Practice Address - Street 2:MAIL STOP 32200A
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-7163
Practice Address - Country:US
Practice Address - Phone:952-431-8500
Practice Address - Fax:952-431-6966
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN45472208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN552432600Medicaid