Provider Demographics
NPI:1588991400
Name:MCGOUGH, SHANNON LEIGH
Entity type:Individual
Prefix:MISS
First Name:SHANNON
Middle Name:LEIGH
Last Name:MCGOUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:453 COLLEGE PKWY
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-1127
Mailing Address - Country:US
Mailing Address - Phone:240-477-5282
Mailing Address - Fax:130-129-5032
Practice Address - Street 1:8901 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20889-5600
Practice Address - Country:US
Practice Address - Phone:301-295-1359
Practice Address - Fax:301-295-0326
Is Sole Proprietor?:No
Enumeration Date:2009-11-13
Last Update Date:2009-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman