Healthcare Provider Details

I. General information

NPI: 1548234701
Provider Name (Legal Business Name): SHANNON HUDSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 10/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 MAIDEN LN THIRD FLOOR
NEW YORK NY
10038-4831
US

IV. Provider business mailing address

90 MAIDEN LN THIRD FLOOR
NEW YORK NY
10038-4831
US

V. Phone/Fax

Practice location:
  • Phone: 646-290-9563
  • Fax: 212-532-4362
Mailing address:
  • Phone: 646-290-9563
  • Fax: 212-532-4362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number211767
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: