Healthcare Provider Details

I. General information

NPI: 1396797239
Provider Name (Legal Business Name): SHANNON CHRISTINE ROBERTS MD FACOG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON CHRISTINE LUIS

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 12/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 E BROADWAY AVE STE 108
JACKSON WY
83001-8640
US

IV. Provider business mailing address

PO BOX 1844
JACKSON WY
83001-1844
US

V. Phone/Fax

Practice location:
  • Phone: 307-734-1005
  • Fax: 307-734-1165
Mailing address:
  • Phone: 307-734-1005
  • Fax: 307-734-1165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number6698A
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: