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General NPI Number Information
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NPI Number | 1245168657
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Entity Type | Individual
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Provider Name | FREDERICK SHANNON
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Gender | Male
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Dates
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Enumeration Date | 05/13/2026
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Last Update Date | 05/13/2026
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Provider Practice Location Address
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Address Line | 2130 SW JEFFERSON ST STE 200
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City | PORTLAND
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State | OR
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Zip | 97201-7710
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Country | US
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Telephone | 971-266-6910
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Fax |
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Provider Business Mailing Address
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Address Line | 5541 SE HENDERSON ST
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City | PORTLAND
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State | OR
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Zip | 97206-8232
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Country | US
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Telephone | 413-262-3228
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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 | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number | A824721
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License Number State | OR
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