Provider Demographics
NPI:1225182637
Name:GULLA, SHANNON M (MD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:GULLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:LYNETTE
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 5083
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38101-5083
Mailing Address - Country:US
Mailing Address - Phone:877-448-8679
Mailing Address - Fax:
Practice Address - Street 1:7600 WOLF RIVER BLVD
Practice Address - Street 2:STE 200
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-1784
Practice Address - Country:US
Practice Address - Phone:901-747-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2008-000552085R0202X
ARE-51602085R0202X
TN420132085R0202X
MS187062085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5910379Medicaid
NC5910379Medicaid