Provider Demographics
NPI:1588661359
Name:SHANAHAN, MARY KELLY (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:KELLY
Last Name:SHANAHAN
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 1:1154 EMERALD BAY RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-6288
Mailing Address - Country:US
Mailing Address - Phone:530-542-4961
Mailing Address - Fax:530-542-4964
Practice Address - Street 1:1154 EMERALD BAY RD
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-6288
Practice Address - Country:US
Practice Address - Phone:530-542-4961
Practice Address - Fax:530-542-4964
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG78582207V00000X
NV7055207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1588661359Medicaid
NV1588661359Medicaid
CACO775ZMedicare PIN
CA00G785820Medicare PIN
CA1588661359Medicaid
NV1588661359Medicaid