Provider Demographics
NPI:1609117175
Name:SHANNON BONNESS MD PC
Entity Type:Organization
Organization Name:SHANNON BONNESS MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:BONNESS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-792-3914
Mailing Address - Street 1:PO BOX 3098
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90510-3098
Mailing Address - Country:US
Mailing Address - Phone:310-792-3914
Mailing Address - Fax:855-898-4055
Practice Address - Street 1:614 W DUARTE RD
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91007-7601
Practice Address - Country:US
Practice Address - Phone:310-792-3914
Practice Address - Fax:855-898-4055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-08
Last Update Date:2013-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC55574207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty