1124167259 NPI number — DR. SHANNON BRIDGET O'BRIEN M.D.

Table of content: DR. SHANNON BRIDGET O'BRIEN M.D. (NPI 1124167259)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124167259 NPI number — DR. SHANNON BRIDGET O'BRIEN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
O'BRIEN
Provider First Name:
SHANNON
Provider Middle Name:
BRIDGET
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124167259
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/05/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1115 SE 164TH AVE DEPT 358
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VANCOUVER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98683-8004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-729-1462
Provider Business Mailing Address Fax Number:
360-729-3104

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3100 TONGASS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KETCHIKAN
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99901-5746
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-321-9900
Provider Business Practice Location Address Fax Number:
907-228-8323
Provider Enumeration Date:
02/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  105120 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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