Healthcare Provider Details

I. General information

NPI: 1710205034
Provider Name (Legal Business Name): SHANNON HAAS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2010
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 SAINT ANN DR STE B
MANDEVILLE LA
70471-3472
US

IV. Provider business mailing address

PO BOX 54482
NEW ORLEANS LA
70154-4482
US

V. Phone/Fax

Practice location:
  • Phone: 985-626-1717
  • Fax: 985-674-2814
Mailing address:
  • Phone: 985-626-1717
  • Fax: 985-674-2814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number206688
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number22866
License Number StateMS
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD.206688
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: