Provider Demographics
NPI:1942352877
Name:SHANNON, BRIAN M (DC)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:M
Last Name:SHANNON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 GODWIN AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WYCKOFF
Mailing Address - State:NJ
Mailing Address - Zip Code:07481-5200
Mailing Address - Country:US
Mailing Address - Phone:201-891-1155
Mailing Address - Fax:201-891-5522
Practice Address - Street 1:260 GODWIN AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:WYCKOFF
Practice Address - State:NJ
Practice Address - Zip Code:07481-5200
Practice Address - Country:US
Practice Address - Phone:201-891-1155
Practice Address - Fax:201-891-5522
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00412700111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJSH703873Medicare ID - Type Unspecified
NJU26316Medicare UPIN