Provider Demographics
NPI:1679562425
Name:SHANNON, MARY ANN
Entity Type:Individual
Prefix:MS
First Name:MARY ANN
Middle Name:
Last Name:SHANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 S RANCHO DR
Mailing Address - Street 2:SUITE I67
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4828
Mailing Address - Country:US
Mailing Address - Phone:702-243-4700
Mailing Address - Fax:702-243-7074
Practice Address - Street 1:501 S RANCHO DR
Practice Address - Street 2:SUITE I-67
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4828
Practice Address - Country:US
Practice Address - Phone:702-243-4700
Practice Address - Fax:702-243-7074
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVD60887207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
D60887Medicare UPIN
NV39616Medicare ID - Type Unspecified