MEDICARE: CAMERON S SHANNON DPT

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
1	225100000X	Physical Therapist	PT4519	AR

General Provider Information

NPI Number	:	1861971509
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAMERON S SHANNON DPT

Provider Business Mailing Address
First Line	:	2504 MCCAIN BLVD STE 230
Second Line	:
City	:	NORTH LITTLE ROCK
State	:	AR
Zip	:	72116-7607
Country	:	US
Telephone Number	:	501-758-5555
Fax Number	:	501-758-5941

Provider Business Practice Location Address
First Line	:	2504 MCCAIN BLVD STE 230
Second Line	:
City	:	NORTH LITTLE ROCK
State	:	AR
Zip	:	72116-7607
Country	:	US
Telephone Number	:	501-758-5555
Fax Number	:	501-758-5941

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/13/2018
Last Update Date	:	01/21/2021

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Directions to “ CAMERON S SHANNON DPT” Practice Location

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