Basic Information
| Provider Information | |||||||||
| NPI: | 1669560603 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLT | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | JANE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COLT-CONNAWAY | ||||||||
| OtherFirstName: | SHANNON | ||||||||
| OtherMiddleName: | JANE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 99 E STATE ST | ||||||||
| Address2: | PO BOX 1250 | ||||||||
| City: | GLOVERSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120781203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187754205 | ||||||||
| FaxNumber: | 5187754225 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 DECKER DRIVE, SUITE 100 | ||||||||
| Address2: | |||||||||
| City: | JOHNSTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120952316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187626731 | ||||||||
| FaxNumber: | 5187627135 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 01/21/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 211113 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 411485 | 01 | NY | MVP HEALTHPLAN | OTHER | 01859278 | 05 | NY | MEDICAID | 000927742002 | 01 | NY | BSH NE NY | OTHER |