Provider Demographics
NPI:1992292437
Name:MCCARTY, SHANNON (DC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:MCCARTY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:HYSONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4760 BANNING AVE STE 218
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-3218
Mailing Address - Country:US
Mailing Address - Phone:651-762-2985
Mailing Address - Fax:
Practice Address - Street 1:4760 BANNING AVE STE 218
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3218
Practice Address - Country:US
Practice Address - Phone:651-762-2985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-19
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6414111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor