Provider Demographics
NPI:1386873958
Name:WELTER, SHANNON (MD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:WELTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 BROCKTON LN N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-3343
Mailing Address - Country:US
Mailing Address - Phone:612-720-8885
Mailing Address - Fax:
Practice Address - Street 1:6401 FRANCE AVE S
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2104
Practice Address - Country:US
Practice Address - Phone:952-924-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-04
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN68273207ZP0102X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program