Provider Demographics
NPI:1922480326
Name:SHANNON, MICHAEL JAMES (ATP)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JAMES
Last Name:SHANNON
Suffix:
Gender:M
Credentials:ATP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2407 WSW LOOP 323
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701
Mailing Address - Country:US
Mailing Address - Phone:903-581-8844
Mailing Address - Fax:909-581-9845
Practice Address - Street 1:12406 STATE HIGHWAY 155 S
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-6446
Practice Address - Country:US
Practice Address - Phone:903-592-8931
Practice Address - Fax:903-592-8922
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-22
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX85900247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other