Healthcare Provider Details

I. General information

NPI: 1093745655
Provider Name (Legal Business Name): JUSTIN R SHANNON NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 10/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2175 ROSALINE AVE
REDDING CA
96001-2509
US

IV. Provider business mailing address

2100 POWELL ST STE 900
EMERYVILLE CA
94608-1844
US

V. Phone/Fax

Practice location:
  • Phone: 530-225-6000
  • Fax: 818-587-2493
Mailing address:
  • Phone: 510-851-7423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberPA15715
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: