Provider Demographics
NPI:1558330712
Name:GREEN, SHANNAN (MD)
Entity type:Individual
Prefix:
First Name:SHANNAN
Middle Name:
Last Name:GREEN
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 1:140 W 11TH ST
Mailing Address - Street 2:
Mailing Address - City:FRONT ROYAL
Mailing Address - State:VA
Mailing Address - Zip Code:22630-3512
Mailing Address - Country:US
Mailing Address - Phone:540-631-3700
Mailing Address - Fax:
Practice Address - Street 1:140 W 11TH ST
Practice Address - Street 2:
Practice Address - City:FRONT ROYAL
Practice Address - State:VA
Practice Address - Zip Code:22630-3512
Practice Address - Country:US
Practice Address - Phone:540-631-3700
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101238191207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA181747OtherANTHEM
VA2134671OtherMAMSI
VA181747OtherCOMM HEALTH
VA714606OtherNCPPO
VA008865F62Medicare ID - Type Unspecified
VA2134671OtherMAMSI