Provider Demographics
NPI:1790149763
Name:DETTY, SHANNON QUIRK (MD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:QUIRK
Last Name:DETTY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:KATHLEEN
Other - Last Name:QUIRK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:600 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53792-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2880 FOLSOM ST STE 200
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-3769
Practice Address - Country:US
Practice Address - Phone:303-442-6647
Practice Address - Fax:303-442-2696
Is Sole Proprietor?:No
Enumeration Date:2016-04-06
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6600-851207N00000X
WI70147207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology