Healthcare Provider Details

I. General information

NPI: 1780797746
Provider Name (Legal Business Name): MICHAEL A SHANNON NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 07/24/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2815 CATES AVE CB 7304
RALEIGH NC
27695-7304
US

IV. Provider business mailing address

2815 CATES AVE CB 7304
RALEIGH NC
27695-7304
US

V. Phone/Fax

Practice location:
  • Phone: 919-515-2563
  • Fax: 888-972-4151
Mailing address:
  • Phone: 919-515-2563
  • Fax: 888-972-4151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number960046
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: