Healthcare Provider Details

I. General information

NPI: 1265510218
Provider Name (Legal Business Name): JACKY DWAYNE SHANNON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 11/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 4TH ST
LUBBOCK TX
79430-0002
US

IV. Provider business mailing address

5004 CR 1435
LUBBOCK TX
79407
US

V. Phone/Fax

Practice location:
  • Phone: 806-743-2981
  • Fax:
Mailing address:
  • Phone: 806-702-4776
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberL8505
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License NumberL8505
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: