Provider Demographics
NPI:1982622601
Name:MYERS, SHANNON WADE (DC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:WADE
Last Name:MYERS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 CHEROKEE RD
Mailing Address - Street 2:12
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-3473
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 BROYLES ST
Practice Address - Street 2:SUITE 6
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-2532
Practice Address - Country:US
Practice Address - Phone:423-610-0005
Practice Address - Fax:423-610-0009
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2000111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4091317OtherBLUE CROSS BLUE SHIELD
TN1407012495OtherGROUP NPI
TN1982622601OtherINDIVIDUAL NPI
TN3727029Medicare ID - Type UnspecifiedPRACTICE NUMBER
TNP00270055Medicare ID - Type UnspecifiedRAILROAD MEDICARE