Provider Demographics
NPI:1386946903
Name:N H SHANNON MD PA
Entity type:Organization
Organization Name:N H SHANNON MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NICK
Authorized Official - Middle Name:H
Authorized Official - Last Name:SHANNON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-532-4555
Mailing Address - Street 1:3326 E SOUTHCROSS BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78223-1922
Mailing Address - Country:US
Mailing Address - Phone:210-532-3216
Mailing Address - Fax:210-532-6055
Practice Address - Street 1:3326 E SOUTHCROSS BLVD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78223-1922
Practice Address - Country:US
Practice Address - Phone:210-532-3216
Practice Address - Fax:210-532-6055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-02
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD2834207Q00000X, 207QG0300X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX092125601Medicaid
TXB26377Medicare UPIN