Provider Demographics
NPI:1609103456
Name:SHANNON A. JOHNSON M.D., PA
Entity Type:Organization
Organization Name:SHANNON A. JOHNSON M.D., PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:ANDREA
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-283-7400
Mailing Address - Street 1:PO BOX 1250
Mailing Address - Street 2:
Mailing Address - City:ROWLETT
Mailing Address - State:TX
Mailing Address - Zip Code:75030-1250
Mailing Address - Country:US
Mailing Address - Phone:817-283-7400
Mailing Address - Fax:817-283-7406
Practice Address - Street 1:3901 AIRPORT FWY
Practice Address - Street 2:SUITE 320
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-6117
Practice Address - Country:US
Practice Address - Phone:817-283-7400
Practice Address - Fax:817-283-7406
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-14
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK7174261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH17712Medicare UPIN