Healthcare Provider Details

I. General information

NPI: 1316383599
Provider Name (Legal Business Name): RYAN T SHANNON MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2013
Last Update Date: 05/03/2023
Certification Date: 05/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7600 N 15TH ST STE 290
PHOENIX AZ
85020-4336
US

IV. Provider business mailing address

PO BOX 41150
MESA AZ
85274-1150
US

V. Phone/Fax

Practice location:
  • Phone: 602-395-0718
  • Fax: 602-277-8146
Mailing address:
  • Phone: 480-425-2160
  • Fax: 480-839-4727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number43015
License Number StateAZ

VIII. Authorized Official

Name: DR. RYAN TAYLOR SHANNON
Title or Position: PHYSICIAN
Credential: MD
Phone: 480-425-2160