Provider Demographics
NPI:1619076114
Name:SHANNON, NICK H (MD)
Entity Type:Individual
Prefix:DR
First Name:NICK
Middle Name:H
Last Name:SHANNON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:N
Other - Middle Name:H
Other - Last Name:SHANNON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3326 E SOUTHCROSS BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78223-1922
Mailing Address - Country:US
Mailing Address - Phone:210-532-3216
Mailing Address - Fax:210-532-2262
Practice Address - Street 1:3326 E SOUTHCROSS BLVD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78223-1922
Practice Address - Country:US
Practice Address - Phone:210-532-3216
Practice Address - Fax:210-532-2262
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD2834207Q00000X, 207QG0300X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX092125601Medicaid
TX00E314Medicare ID - Type Unspecified
TX092125601Medicaid