Provider Demographics
NPI:1861640450
Name:BOHAN, SHANNON R (MED)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:R
Last Name:BOHAN
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 E RIVER RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85718-6508
Mailing Address - Country:US
Mailing Address - Phone:520-209-7700
Mailing Address - Fax:520-209-7570
Practice Address - Street 1:2101 E RIVER RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85718-6508
Practice Address - Country:US
Practice Address - Phone:520-209-7700
Practice Address - Fax:520-209-7570
Is Sole Proprietor?:No
Enumeration Date:2008-09-08
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1827273101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool