Healthcare Provider Details

I. General information

NPI: 1023067550
Provider Name (Legal Business Name): SHANNON SWANSON DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 06/30/2023
Certification Date: 06/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

158 W MAIN RD
CONNEAUT OH
44030-2039
US

IV. Provider business mailing address

4535 DRESSLER RD NW
CANTON OH
44718-2545
US

V. Phone/Fax

Practice location:
  • Phone: 330-493-4443
  • Fax: 330-493-8677
Mailing address:
  • Phone: 330-493-4443
  • Fax: 330-493-8677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number34008887
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: