Basic Information
Provider Information | |||||||||
NPI: | 1598715278 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CALHOUN | ||||||||
FirstName: | SHANNON | ||||||||
MiddleName: | PATRICK | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | NANCE | ||||||||
OtherFirstName: | SHANNON | ||||||||
OtherMiddleName: | PATRICK | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 17310 WRIGHT ST STE 103 | ||||||||
Address2: |   | ||||||||
City: | OMAHA | ||||||||
State: | NE | ||||||||
PostalCode: | 681302405 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8332286889 | ||||||||
FaxNumber: | 8778530376 | ||||||||
Practice Location | |||||||||
Address1: | 17310 WRIGHT ST STE 103 | ||||||||
Address2: |   | ||||||||
City: | OMAHA | ||||||||
State: | NE | ||||||||
PostalCode: | 681302405 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8332286889 | ||||||||
FaxNumber: | 8778530376 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/11/2006 | ||||||||
LastUpdateDate: | 10/24/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/24/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 11128 | ND | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 8028A | WY | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 3654 | OK | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.