Provider Demographics
NPI:1881030997
Name:ST. CLAIR, SHANNON LAREE (MD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LAREE
Last Name:ST. CLAIR
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 1:17310 WRIGHT ST STE 103
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68130-2405
Mailing Address - Country:US
Mailing Address - Phone:833-228-6889
Mailing Address - Fax:877-853-0376
Practice Address - Street 1:5757 COLEY AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-5335
Practice Address - Country:US
Practice Address - Phone:952-595-1100
Practice Address - Fax:612-294-4903
Is Sole Proprietor?:No
Enumeration Date:2013-05-15
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUM-24192085R0202X
ND162542085R0202X
GUMTL-2023-0262085R0202X
WY13105C2085R0202X
NV184822085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology