Provider Demographics
NPI:1588891097
Name:BIBIS, SHANNON M (NP)
Entity type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:M
Last Name:BIBIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1336 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53172-1133
Mailing Address - Country:US
Mailing Address - Phone:414-940-0278
Mailing Address - Fax:414-301-9508
Practice Address - Street 1:725 AMERICAN AVE
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-5031
Practice Address - Country:US
Practice Address - Phone:262-928-2594
Practice Address - Fax:414-805-5809
Is Sole Proprietor?:No
Enumeration Date:2009-06-11
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI156515363L00000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1588891097Medicaid
WI736011586Medicare PIN