Provider Demographics
NPI:1932119450
Name:ROSE, SHANNON (MD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:ROSE
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 1:275 E 200 S
Mailing Address - Street 2:VISTA
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-2002
Mailing Address - Country:US
Mailing Address - Phone:800-366-1884
Mailing Address - Fax:866-360-6021
Practice Address - Street 1:275 E 200 S
Practice Address - Street 2:VISTA
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-4111
Practice Address - Country:US
Practice Address - Phone:800-366-1884
Practice Address - Fax:866-360-6021
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG77178207R00000X, 208000000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics