Basic Information
| Provider Information | |||||||||
| NPI: | 1063807022 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHANNON | ||||||||
| FirstName: | KRISTOPHER | ||||||||
| MiddleName: | RYAN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 655 WEST 8TH STREET, C506 | ||||||||
| Address2: | 1ST FLOOR CLINICAL CENTER | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042443817 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | DIGNITY HEALTH, NORTH LAS VEGAS CAMPUS | ||||||||
| Address2: | 1550 W. CRAIG RD | ||||||||
| City: | NORTH LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7027773615 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2015 | ||||||||
| LastUpdateDate: | 06/08/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 17765 | NV | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 12009729-1205 | UT | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.