Provider Demographics
NPI:1891561130
Name:NELSON, SHANNON JEAN (RDMS)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:JEAN
Last Name:NELSON
Suffix:
Gender:F
Credentials:RDMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 NOB RD
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-5520
Mailing Address - Country:US
Mailing Address - Phone:315-542-7376
Mailing Address - Fax:
Practice Address - Street 1:8200 SENECA TPKE
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NY
Practice Address - Zip Code:13323-1027
Practice Address - Country:US
Practice Address - Phone:315-542-7376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-28
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1083532085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound