Provider Demographics
NPI:1699414243
Name:POULOSE, SHANNON (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
Last Name:POULOSE
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 1:222 STATION PLZ N STE 509
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-3893
Mailing Address - Country:US
Mailing Address - Phone:516-663-2381
Mailing Address - Fax:
Practice Address - Street 1:222 STATION PLZ N STE 509
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-3893
Practice Address - Country:US
Practice Address - Phone:516-663-2381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-01
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program