Provider Demographics
NPI:1316933542
Name:MEYER, SHANNON S (DPM)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:S
Last Name:MEYER
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7428 LOON LANDING SHORES
Mailing Address - Street 2:
Mailing Address - City:LAKE TOMAHAWK
Mailing Address - State:WI
Mailing Address - Zip Code:54539-9110
Mailing Address - Country:US
Mailing Address - Phone:877-265-5225
Mailing Address - Fax:715-277-4944
Practice Address - Street 1:311 ELM ST
Practice Address - Street 2:
Practice Address - City:WOODRUFF
Practice Address - State:WI
Practice Address - Zip Code:54568-9149
Practice Address - Country:US
Practice Address - Phone:715-634-9023
Practice Address - Fax:715-634-9935
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2017-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI726-25213ES0103X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43222500Medicaid
CG4176OtherRAILROAD MEDICARE
WI000280300Medicare PIN
U63276Medicare UPIN
WI43222500Medicaid