Healthcare Provider Details

I. General information

NPI: 1154338440
Provider Name (Legal Business Name): SHANNON COLE WINN CPO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 03/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1075 S IDAHO RD SUITE 101
APACHE JUNCTION AZ
85219-6496
US

IV. Provider business mailing address

1075 S IDAHO RD SUITE 101
APACHE JUNCTION AZ
85219-6496
US

V. Phone/Fax

Practice location:
  • Phone: 480-982-3000
  • Fax: 480-982-3103
Mailing address:
  • Phone: 480-982-3000
  • Fax: 480-982-3103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License NumberCPO02652
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: