Healthcare Provider Details

I. General information

NPI: 1730614579
Provider Name (Legal Business Name): TIMOTHY PATRICK SHANNON BSN, RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2017
Last Update Date: 02/10/2024
Certification Date: 02/10/2024
Deactivation Date: 02/01/2024
Reactivation Date: 02/08/2024

III. Provider practice location address

9245 RAINIER AVE S
SEATTLE WA
98118-5569
US

IV. Provider business mailing address

4005 15TH AVE NE APT 406
SEATTLE WA
98105-6249
US

V. Phone/Fax

Practice location:
  • Phone: 206-612-2866
  • Fax:
Mailing address:
  • Phone: 206-612-8666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN61217405
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License NumberPC60752642
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: