Provider Demographics
NPI:1194888552
Name:BRODERSON, SHANNON MARIE (DC)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:MARIE
Last Name:BRODERSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:SHANNON
Other - Middle Name:MARIE
Other - Last Name:HOGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:74-5620 PALANI RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96740-3640
Mailing Address - Country:US
Mailing Address - Phone:808-329-7797
Mailing Address - Fax:808-329-2748
Practice Address - Street 1:74-5620 PALANI RD
Practice Address - Street 2:SUITE 102
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-3640
Practice Address - Country:US
Practice Address - Phone:808-329-7797
Practice Address - Fax:808-329-2748
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDC977111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI244327OtherHMSA NUMBER
HIH56328OtherP-TAN
HIH56328OtherP-TAN