Healthcare Provider Details

I. General information

NPI: 1366551285
Provider Name (Legal Business Name): MICHAEL H SHANNON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 04/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2555 MARVIN RD NE PMG SW WA OLYMPIA ENDOCRINE
LACEY WA
98516-3138
US

IV. Provider business mailing address

PO BOX 3360
PORTLAND OR
97208-3360
US

V. Phone/Fax

Practice location:
  • Phone: 360-413-4250
  • Fax: 360-413-4256
Mailing address:
  • Phone: 360-486-6508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberMD00042625
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: