Basic Information
| Provider Information | |||||||||
| NPI: | 1003020660 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TIERNEY | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD, MS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCELEARNEY | ||||||||
| OtherFirstName: | SHANNON | ||||||||
| OtherMiddleName: | T | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD, MS | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 388 | ||||||||
| Address2: | |||||||||
| City: | FISHERSVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229390388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5409325162 | ||||||||
| FaxNumber: | 5409325875 | ||||||||
| Practice Location | |||||||||
| Address1: | 70 MEDICAL CENTER CIR STE 107&213 | ||||||||
| Address2: | |||||||||
| City: | FISHERSVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229392273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5402457705 | ||||||||
| FaxNumber: | 5402457710 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2007 | ||||||||
| LastUpdateDate: | 04/14/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | MD60090634 | WA | N | Allopathic & Osteopathic Physicians | Surgery | 2086X0206X | 249543 | NY | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology | 390200000X | 0116014011 | VA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208600000X | 0101267589 | VA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1003020660 | 05 | VA | MEDICAID |