Healthcare Provider Details

I. General information

NPI: 1649218454
Provider Name (Legal Business Name): MICHAEL J SHANNON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 12/20/2022
Certification Date: 12/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4017 RAWLINS ST
CHEYENNE WY
82001-1800
US

IV. Provider business mailing address

PO BOX 20970
CHEYENNE WY
82003-7020
US

V. Phone/Fax

Practice location:
  • Phone: 307-635-2562
  • Fax: 307-638-2074
Mailing address:
  • Phone: 307-635-2562
  • Fax: 307-638-2074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number7800A
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: