Provider Demographics
NPI:1184825036
Name:SHANNON, DEAN A (LMP)
Entity type:Individual
Prefix:MR
First Name:DEAN
Middle Name:A
Last Name:SHANNON
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 24142
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98093-1142
Mailing Address - Country:US
Mailing Address - Phone:253-475-7317
Mailing Address - Fax:253-474-3540
Practice Address - Street 1:1702 S 72ND ST
Practice Address - Street 2:SUITE A
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98408-1238
Practice Address - Country:US
Practice Address - Phone:253-475-7317
Practice Address - Fax:253-474-3540
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00008235172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist