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NPI Code Detail

MEDICARE: DR. SHANNON E FULP M.D.

MEDICARE: DR. SHANNON E FULP M.D.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207Y00000XOtolaryngology Physician0101279712VA

General Provider Information

NPI Number : 1487649414
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. SHANNON E FULP M.D.
Provider Business Mailing Address
First Line : 213 S JEFFERSON ST STE 1006
Second Line : STE 1006
City : ROANOKE
State : VA
Zip : 24011-1713
Country : US
Telephone Number : 540-224-5516
Fax Number :
Provider Business Practice Location Address
First Line : 4348 ELECTRIC RD
Second Line :
City : ROANOKE
State : VA
Zip : 24018-0720
Country : US
Telephone Number : 540-769-0700
Fax Number : 540-772-8159
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/15/2005
Last Update Date : 05/21/2026

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