Provider Demographics
NPI:1992811947
Name:HECK, SHANON IONE (MD)
Entity type:Individual
Prefix:
First Name:SHANON
Middle Name:IONE
Last Name:HECK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:IONE
Other - Last Name:SCHULTZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11130 N TATUM BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-1662
Mailing Address - Country:US
Mailing Address - Phone:602-494-1817
Mailing Address - Fax:602-494-7103
Practice Address - Street 1:11130 N TATUM BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-1662
Practice Address - Country:US
Practice Address - Phone:602-494-1817
Practice Address - Fax:602-494-7103
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ35454207N00000X
VA0101235064207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010227844Medicaid
VA008222P05Medicare ID - Type Unspecified
VA010227844Medicaid