Provider Demographics
NPI:1487707451
Name:SHANNON, GREG (LAC, MAC)
Entity type:Individual
Prefix:
First Name:GREG
Middle Name:
Last Name:SHANNON
Suffix:
Gender:M
Credentials:LAC, MAC
Other - Prefix:
Other - First Name:GREGORY
Other - Middle Name:W
Other - Last Name:SHANNON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LAC, MAC
Mailing Address - Street 1:313 OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:CASHMERE
Mailing Address - State:WA
Mailing Address - Zip Code:98815-1126
Mailing Address - Country:US
Mailing Address - Phone:509-886-4554
Mailing Address - Fax:509-782-9255
Practice Address - Street 1:304 GRANT RD
Practice Address - Street 2:SUITE 2
Practice Address - City:EAST WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98802-5384
Practice Address - Country:US
Practice Address - Phone:509-886-4554
Practice Address - Fax:509-782-9255
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC00000659171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist