Healthcare Provider Details

I. General information

NPI: 1427192459
Provider Name (Legal Business Name): SHANNON L SHEVOCK-JOHNSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHANNON L SHEVOCK MD

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 11/10/2020
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2925 CHICAGO AVE
MINNEAPOLIS MN
55407-1321
US

IV. Provider business mailing address

3396 VICTORIA ST N
SHOREVIEW MN
55126-3862
US

V. Phone/Fax

Practice location:
  • Phone: 612-262-3738
  • Fax: 612-262-4258
Mailing address:
  • Phone: 202-680-2260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number232775
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: