Provider Demographics
NPI:1316975683
Name:PETERSON, SHANNON (DC)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N275 MILITARY RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SHERWOOD
Mailing Address - State:WI
Mailing Address - Zip Code:54169-9603
Mailing Address - Country:US
Mailing Address - Phone:920-989-1599
Mailing Address - Fax:920-989-1593
Practice Address - Street 1:N275 MILITARY RD
Practice Address - Street 2:SUITE 2
Practice Address - City:SHERWOOD
Practice Address - State:WI
Practice Address - Zip Code:54169-9603
Practice Address - Country:US
Practice Address - Phone:920-989-1599
Practice Address - Fax:920-989-1593
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3809-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38937000Medicaid
WI38937000Medicaid
WIU88756Medicare UPIN