Provider Demographics
NPI:1649218454
Name:SHANNON, MICHAEL J (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:SHANNON
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:PO BOX 20970
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82003-7020
Mailing Address - Country:US
Mailing Address - Phone:307-635-2562
Mailing Address - Fax:307-638-2074
Practice Address - Street 1:4017 RAWLINS ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-1800
Practice Address - Country:US
Practice Address - Phone:307-635-2562
Practice Address - Fax:307-638-2074
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY7800A207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY125526600Medicaid
WYP00649757OtherRAILROAD MEDICARE
CO93574363Medicaid
I30288Medicare UPIN
WYP00649757OtherRAILROAD MEDICARE