Healthcare Provider Details

I. General information

NPI: 1578534269
Provider Name (Legal Business Name): SHANNON JO PARKOS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON JO REEDY

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 10/31/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15350 ENGLISH AVE
APPLE VALLEY MN
55124-6252
US

IV. Provider business mailing address

8170 33RD AVE S # MS 21110Q
BLOOMINGTON MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 952-431-8500
  • Fax: 952-431-6966
Mailing address:
  • Phone: 952-883-4950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number45472
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: