Provider Demographics
NPI:1821480864
Name:SHANNON EASTON-CARR, MD, INC
Entity Type:Organization
Organization Name:SHANNON EASTON-CARR, MD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:EASTON-CARR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-762-4739
Mailing Address - Street 1:1241 JOHNSON AVE
Mailing Address - Street 2:BOX 313
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-3306
Mailing Address - Country:US
Mailing Address - Phone:805-762-4739
Mailing Address - Fax:888-462-8045
Practice Address - Street 1:895 AEROVISTA PL STE 106
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-8725
Practice Address - Country:US
Practice Address - Phone:805-762-4739
Practice Address - Fax:805-462-8045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-27
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1114112084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty