Provider Demographics
NPI:1659831584
Name:SHANNON, CHARLES MAXWELL
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:MAXWELL
Last Name:SHANNON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7010 STAFFORDSHIRE BLVD APT 147
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-4128
Mailing Address - Country:US
Mailing Address - Phone:214-546-5308
Mailing Address - Fax:
Practice Address - Street 1:1 BAYLOR PLZ
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-3498
Practice Address - Country:US
Practice Address - Phone:214-546-5308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-25
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program