Provider Demographics
NPI:1629125356
Name:WYMAN, SHANNON R (DC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:R
Last Name:WYMAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 7TH AVE STE 230
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-4949
Mailing Address - Country:US
Mailing Address - Phone:907-456-4234
Mailing Address - Fax:907-451-9168
Practice Address - Street 1:515 7TH AVE STE 230
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4949
Practice Address - Country:US
Practice Address - Phone:907-456-4234
Practice Address - Fax:907-451-9168
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK0408111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCH0408Medicaid
AK1004390Medicaid
AKCH0408Medicaid