Basic Information
| Provider Information | |||||||||
| NPI: | 1740475920 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FALCON | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | REED | ||||||||
| OtherFirstName: | SHANNON | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 12902 MAGNOLIA DR. | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888602778 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12902 MAGNOLIA DR. | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888602778 | ||||||||
| FaxNumber: | 8133555099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2007 | ||||||||
| LastUpdateDate: | 05/02/2013 | ||||||||
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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 | 2085R0202X | ME106718 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 006305100 | 05 | FL | MEDICAID | 14L46 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER | P01135662 | 01 | FL | R&R MEDICARE | OTHER |