Healthcare Provider Details

I. General information

NPI: 1669560603
Provider Name (Legal Business Name): SHANNON JANE COLT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON JANE COLT-CONNAWAY MD

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 01/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 DECKER DRIVE, SUITE 100
JOHNSTOWN NY
12095-2316
US

IV. Provider business mailing address

99 E STATE ST PO BOX 1250
GLOVERSVILLE NY
12078-1203
US

V. Phone/Fax

Practice location:
  • Phone: 518-762-6731
  • Fax: 518-762-7135
Mailing address:
  • Phone: 518-775-4205
  • Fax: 518-775-4225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number211113
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: