Provider Demographics
NPI:1023054624
Name:MEADS, SHANNA BURRIS (MD)
Entity type:Individual
Prefix:
First Name:SHANNA
Middle Name:BURRIS
Last Name:MEADS
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 1:1367 DOMINION PLZ
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-1013
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1367 DOMINION PLZ
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-1013
Practice Address - Country:US
Practice Address - Phone:903-534-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM0820207N00000X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX173749601Medicaid
TXP00228994OtherRAILROAD MEDICARE PTAN
TX8A2684OtherBLUE CROSS AND BLUE SHIELD
TXP00228994OtherRAILROAD MEDICARE PTAN
TX8E0392Medicare PIN