Healthcare Provider Details

I. General information

NPI: 1154307049
Provider Name (Legal Business Name): SHANNON LEE BRAUN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2560 N. SHADELAND AVENUE SUITE A
INDIANAPOLIS IN
46219-1706
US

IV. Provider business mailing address

2560 N. SHADELAND AVENUE SUITE A
INDIANAPOLIS IN
46219-1706
US

V. Phone/Fax

Practice location:
  • Phone: 317-275-8072
  • Fax: 317-275-8018
Mailing address:
  • Phone: 317-275-8072
  • Fax: 317-275-8018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number01044695A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: