Basic Information
| Provider Information | |||||||||
| NPI: | 1477575611 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KNAGGS | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1951 | ||||||||
| Address2: | SAINT RAPHAEL PHYSICIANS | ||||||||
| City: | BRATTLEBORO | ||||||||
| State: | VT | ||||||||
| PostalCode: | 053021951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085950531 | ||||||||
| FaxNumber: | 5088295367 | ||||||||
| Practice Location | |||||||||
| Address1: | 1450 CHAPEL STREET | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037894074 | ||||||||
| FaxNumber: | 2038675534 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 09/18/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 001902 | CT | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 004193116 | 05 | CT | MEDICAID |