Provider Demographics
NPI:1972895779
Name:BECKER, SHANNON C (MD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:C
Last Name:BECKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10470 OLD PLACERVILLE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:855-771-0335
Mailing Address - Fax:
Practice Address - Street 1:2210 DEL PASO RD
Practice Address - Street 2:SUITE A
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95834-9676
Practice Address - Country:US
Practice Address - Phone:916-285-3100
Practice Address - Fax:916-285-8115
Is Sole Proprietor?:No
Enumeration Date:2011-05-11
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA121997207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFP2374Medicare PIN