Provider Demographics
NPI:1588716260
Name:TYSON-POLETTI, SHANNON C (MD)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:C
Last Name:TYSON-POLETTI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SHANNON
Other - Middle Name:C
Other - Last Name:POLETTI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:9485 W COLFAX AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80215-3918
Mailing Address - Country:US
Mailing Address - Phone:303-425-0300
Mailing Address - Fax:303-432-5530
Practice Address - Street 1:9485 W COLFAX AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80215
Practice Address - Country:US
Practice Address - Phone:303-425-0300
Practice Address - Fax:303-432-5530
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO367972084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
COF88349Medicare UPIN
COC7619Medicare PIN