Provider Demographics
NPI:1740535939
Name:SHANNON, BRIAN L
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:L
Last Name:SHANNON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9152
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26506-9152
Mailing Address - Country:US
Mailing Address - Phone:304-288-4096
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CENTER DRIVE
Practice Address - Street 2:LEVEL 1, HSC SOUTH
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26506-9152
Practice Address - Country:US
Practice Address - Phone:304-288-4096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-13
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAT0011712255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer