Provider Demographics
NPI:1982833323
Name:SCURLOCK, SHANNON D SR
Entity Type:Individual
Prefix:MR
First Name:SHANNON
Middle Name:D
Last Name:SCURLOCK
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12808 W AIRPORT BLVD STE 292
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77478-6244
Mailing Address - Country:US
Mailing Address - Phone:832-392-2886
Mailing Address - Fax:
Practice Address - Street 1:12808 W AIRPORT BLVD STE 292
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77478-6244
Practice Address - Country:US
Practice Address - Phone:832-392-2886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-07
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247200000X
TX247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other