Provider Demographics
NPI:1740714039
Name:UNRUH, SHANNON (RN)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:UNRUH
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4914 LINCOLN BLVD
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:CA
Mailing Address - Zip Code:95334-9640
Mailing Address - Country:US
Mailing Address - Phone:209-620-2005
Mailing Address - Fax:
Practice Address - Street 1:936 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95340-4519
Practice Address - Country:US
Practice Address - Phone:209-285-9002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-13
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95052240261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care