Provider Demographics
NPI:1295922912
Name:CLARK, SHANNON (MD)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
Last Name:CLARK
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 1:4860 Y ST
Mailing Address - Street 2:SUITE 2500
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-2307
Mailing Address - Country:US
Mailing Address - Phone:916-734-8445
Mailing Address - Fax:916-734-6666
Practice Address - Street 1:4860 Y ST
Practice Address - Street 2:SUITE 2500
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2307
Practice Address - Country:US
Practice Address - Phone:916-734-8445
Practice Address - Fax:916-734-6666
Is Sole Proprietor?:No
Enumeration Date:2007-09-26
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA103021207Q00000X, 207VX0000X
CAA1031212084B0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
No2084B0040XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyBehavioral Neurology & Neuropsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00000OtherMEDICAL