Provider Demographics
NPI:1912649310
Name:BREWER, SHANNON (DO)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BREWER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3320 CAMP BOWIE BLVD APT 2110
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-2756
Mailing Address - Country:US
Mailing Address - Phone:903-748-7115
Mailing Address - Fax:
Practice Address - Street 1:1501 N CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85724-7101
Practice Address - Country:US
Practice Address - Phone:520-694-8888
Practice Address - Fax:520-694-2353
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-07
Last Update Date:2025-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZR4528207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program