Healthcare Provider Details

I. General information

NPI: 1588661359
Provider Name (Legal Business Name): MARY KELLY SHANAHAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 04/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1154 EMERALD BAY RD
SOUTH LAKE TAHOE CA
96150-6288
US

IV. Provider business mailing address

1154 EMERALD BAY RD
SOUTH LAKE TAHOE CA
96150-6288
US

V. Phone/Fax

Practice location:
  • Phone: 530-542-4961
  • Fax: 530-542-4964
Mailing address:
  • Phone: 530-542-4961
  • Fax: 530-542-4964

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberG78582
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number7055
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: