Basic Information
| Provider Information | |||||||||
| NPI: | 1023470267 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROCHE | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | D.O | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60447 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282600447 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 7903 PROVIDENCE RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282779763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043164460 | ||||||||
| FaxNumber: | 7043164466 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2016 | ||||||||
| LastUpdateDate: | 10/26/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2019-00816 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.