Provider Demographics
NPI:1366551285
Name:SHANNON, MICHAEL H (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:H
Last Name:SHANNON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3360
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3360
Mailing Address - Country:US
Mailing Address - Phone:360-486-6508
Mailing Address - Fax:
Practice Address - Street 1:2555 MARVIN RD NE
Practice Address - Street 2:PMG SW WA OLYMPIA ENDOCRINE
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-3138
Practice Address - Country:US
Practice Address - Phone:360-413-4250
Practice Address - Fax:360-413-4256
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00042625207RE0101X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism