Healthcare Provider Details

I. General information

NPI: 1891088910
Provider Name (Legal Business Name): SHANNON DAVIS WISE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON LEIGH DAVIS MD

II. Dates (important events)

Enumeration Date: 05/23/2011
Last Update Date: 03/10/2021
Certification Date: 03/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 GOODLETTE-FRANK RD N STE 100
NAPLES FL
34102-5617
US

IV. Provider business mailing address

PO BOX 25487
SARASOTA FL
34277-2487
US

V. Phone/Fax

Practice location:
  • Phone: 239-351-2990
  • Fax: 239-300-4128
Mailing address:
  • Phone: 941-202-5342
  • Fax: 855-253-4836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberME120329
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number16178
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME120329
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: