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General NPI Number Information
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NPI Number | 1063807022
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Entity Type | Individual
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Provider Name | KRISTOPHER RYAN SHANNON M.D.
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Gender | Male
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Dates
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Enumeration Date | 04/06/2015
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Last Update Date | 10/17/2025
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Provider Practice Location Address
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Address Line | 850 YELLOWSTONE AVE
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City | POCATELLO
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State | ID
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Zip | 83201-4415
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Country | US
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Telephone | 208-239-8065
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Fax |
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Provider Business Mailing Address
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Address Line | 98 POPLAR ST
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City | BLACKFOOT
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State | ID
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Zip | 83221-1799
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Country | US
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Telephone | 208-785-3813
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | M-16351
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 12009729-1205
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License Number State | UT
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Taxonomy #3
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 17765
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License Number State | NV
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Taxonomy #4
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Taxonomy Code | 261QU0200X
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Taxonomy Name | Urgent Care Clinic/Center
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License Number | M-16351
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License Number State | ID
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