Provider Demographics
NPI:1477769677
Name:COTHRAN, SHANNON (MD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:COTHRAN
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 1:2010 CORPORATE RDG
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22102-7853
Mailing Address - Country:US
Mailing Address - Phone:571-297-4200
Mailing Address - Fax:571-297-4200
Practice Address - Street 1:2010 CORPORATE RDG STE 510
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22102-7838
Practice Address - Country:US
Practice Address - Phone:571-297-4200
Practice Address - Fax:571-297-4551
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101243468207VG0400X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA138514ZBVWMedicare UPIN