Healthcare Provider Details

I. General information

NPI: 1124087317
Provider Name (Legal Business Name): KAREN WANG SHANNON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 11/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

812 NW 57TH ST
GAINESVILLE FL
32605-6414
US

IV. Provider business mailing address

8976 SW 11TH AVE
GAINESVILLE FL
32607-4962
US

V. Phone/Fax

Practice location:
  • Phone: 352-519-5420
  • Fax: 352-333-6249
Mailing address:
  • Phone: 352-219-8104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberME81339
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberME81339
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: