Provider Demographics
NPI:1124524699
Name:ZEHTABAN, SHANNON PETRUS (MD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:PETRUS
Last Name:ZEHTABAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:NICOLE
Other - Last Name:PETRUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:9500 KANIS RD STE 501
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-6389
Mailing Address - Country:US
Mailing Address - Phone:501-227-9080
Mailing Address - Fax:501-227-0410
Practice Address - Street 1:9500 KANIS RD STE 501
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6389
Practice Address - Country:US
Practice Address - Phone:501-227-9080
Practice Address - Fax:501-227-0410
Is Sole Proprietor?:No
Enumeration Date:2018-04-03
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-16971208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery