Provider Demographics
NPI:1689093395
Name:MCCONNAUGHEY, SHANNON (MD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:MCCONNAUGHEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3525 E LOUISE DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6302
Mailing Address - Country:US
Mailing Address - Phone:208-322-1680
Mailing Address - Fax:
Practice Address - Street 1:3525 E LOUISE DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6302
Practice Address - Country:US
Practice Address - Phone:256-468-8178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-09
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-15691207RC0000X
WAMD60683655207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8966461OtherMEDICARE PIN
WA1689093395Medicaid