Provider Demographics
NPI:1609083336
Name:SHIANNA, SHAWN ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:ALLEN
Last Name:SHIANNA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1030 S KUNKLE BLVD
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-6914
Mailing Address - Country:US
Mailing Address - Phone:815-599-7850
Mailing Address - Fax:815-235-1310
Practice Address - Street 1:1030 S KUNKLE BLVD
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-6914
Practice Address - Country:US
Practice Address - Phone:815-599-7850
Practice Address - Fax:815-235-1310
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036078475207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036078475Medicaid
ILE18457Medicare UPIN
ILR03119Medicare PIN