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General NPI Number Information
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NPI Number | 1396938916
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Entity Type | Individual
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Provider Name | SHANNON M BRODERSEN M.D.
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Gender | Female
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Dates
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Enumeration Date | 08/27/2007
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Last Update Date | 09/10/2025
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Provider Practice Location Address
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Address Line | 16528 E DESMET CT STE B2100
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City | SPOKANE VALLEY
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State | WA
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Zip | 99216-3522
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Country | US
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Telephone | 509-944-9440
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Fax | 509-227-7070
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Provider Business Mailing Address
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Address Line | POB 31001-4114
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City | PASADENA
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State | CA
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Zip | 91110-0001
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Country | US
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Telephone | 866-747-2455
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Fax | 509-944-9644
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | MD 60474752
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License Number State | WA
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