Provider Demographics
NPI:1487971263
Name:WILLIS, SHANNON TERESA (MD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:TERESA
Last Name:WILLIS
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 1:1000 MEDICAL CENTER BLVD
Mailing Address - Street 2:GROUND FLOOR GME OFFICE
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-7694
Mailing Address - Country:US
Mailing Address - Phone:706-593-1389
Mailing Address - Fax:
Practice Address - Street 1:1000 MEDICAL CENTER BLVD
Practice Address - Street 2:GROUND FLOOR GME OFFICE
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-7694
Practice Address - Country:US
Practice Address - Phone:706-593-1389
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-03
Last Update Date:2025-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA075178207R00000X, 208M00000X
MEMD29422207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine