Provider Demographics
NPI:1710248653
Name:PEGRAM, SHANNEL ANYAE (DO)
Entity Type:Individual
Prefix:
First Name:SHANNEL
Middle Name:ANYAE
Last Name:PEGRAM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RAF LAKENHEATH 48 MDG/SGHC
Mailing Address - Street 2:UNIT 5115
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09461-5115
Mailing Address - Country:US
Mailing Address - Phone:016-385-2812
Mailing Address - Fax:
Practice Address - Street 1:UNIT 5115 BOX MDG
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09461-5115
Practice Address - Country:US
Practice Address - Phone:314-226-8852
Practice Address - Fax:314-226-8852
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-07
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC183218207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine