Provider Demographics
NPI:1891088910
Name:WISE, SHANNON DAVIS (MD)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:DAVIS
Last Name:WISE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:SHANNON
Other - Middle Name:LEIGH
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 25487
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34277-2487
Mailing Address - Country:US
Mailing Address - Phone:941-202-5342
Mailing Address - Fax:855-253-4836
Practice Address - Street 1:730 GOODLETTE-FRANK RD N STE 100
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102-5617
Practice Address - Country:US
Practice Address - Phone:239-351-2990
Practice Address - Fax:239-300-4128
Is Sole Proprietor?:No
Enumeration Date:2011-05-23
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME120329208M00000X, 207R00000X
FL16178390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012206800Medicaid
FLHV151YOtherMEDICARE
FL14W2LOtherBCBS