Provider Demographics
NPI:1477057883
Name:ALTAZAN, SHANNON WAYNE (DO)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:WAYNE
Last Name:ALTAZAN
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:284 BELL BLVD
Mailing Address - Street 2:
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062-3321
Mailing Address - Country:US
Mailing Address - Phone:225-802-2197
Mailing Address - Fax:
Practice Address - Street 1:401 MATTHEW ST
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-1635
Practice Address - Country:US
Practice Address - Phone:740-376-1939
Practice Address - Fax:740-374-1693
Is Sole Proprietor?:No
Enumeration Date:2018-03-20
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.015793207P00000X, 207P00000X
WV3742207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0485813Medicaid