Provider Demographics
NPI:1508277575
Name:SUTHERLAND, SHANNON MCKERNAN (MD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MCKERNAN
Last Name:SUTHERLAND
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:MARY
Other - Last Name:MCKERNAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:330 WESTERN BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-4383
Mailing Address - Country:US
Mailing Address - Phone:860-547-0306
Mailing Address - Fax:860-525-9782
Practice Address - Street 1:330 WESTERN BLVD STE 102
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033
Practice Address - Country:US
Practice Address - Phone:860-547-0306
Practice Address - Fax:860-525-9782
Is Sole Proprietor?:No
Enumeration Date:2014-05-13
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT61130207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology