Healthcare Provider Details

I. General information

NPI: 1760571079
Provider Name (Legal Business Name): DOROTHY SHANNON CNM, NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 02/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1755 COBURG RD BLDG 1, SUITE 2
EUGENE OR
97401-4982
US

IV. Provider business mailing address

1755 COBURG RD BLDG 1, SUITE 2
EUGENE OR
97401-4982
US

V. Phone/Fax

Practice location:
  • Phone: 541-984-3000
  • Fax: 541-485-7266
Mailing address:
  • Phone: 541-984-3000
  • Fax: 541-485-7266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number080045016N5
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number080045015
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierR165420
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerMEDICARE PTAN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: