Provider Demographics
NPI:1952847253
Name:BISHOP, SHANNON ELAN
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:ELAN
Last Name:BISHOP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:994 S HARRISON RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85748-6608
Mailing Address - Country:US
Mailing Address - Phone:520-721-1887
Mailing Address - Fax:
Practice Address - Street 1:250 E CONGRESS AVE
Practice Address - Street 2:
Practice Address - City:COOLIDGE
Practice Address - State:AZ
Practice Address - Zip Code:85128-4519
Practice Address - Country:US
Practice Address - Phone:520-560-1545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-10
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1783777171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor