Basic Information
| Provider Information | |||||||||
| NPI: | 1184825036 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHANNON | ||||||||
| FirstName: | DEAN | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LMP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 24142 | ||||||||
| Address2: | |||||||||
| City: | FEDERAL WAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980931142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2534757317 | ||||||||
| FaxNumber: | 2534743540 | ||||||||
| Practice Location | |||||||||
| Address1: | 1702 S 72ND ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984081238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2534757317 | ||||||||
| FaxNumber: | 2534743540 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172M00000X | MA00008235 | WA | Y | Other Service Providers | Mechanotherapist |
No ID Information.