Basic Information
| Provider Information | |||||||||
| NPI: | 1790149763 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DETTY | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | QUIRK | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | QUIRK | ||||||||
| OtherFirstName: | SHANNON | ||||||||
| OtherMiddleName: | KATHLEEN | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 600 HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537920001 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2880 FOLSOM ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803043769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034426647 | ||||||||
| FaxNumber: | 3034422696 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2016 | ||||||||
| LastUpdateDate: | 10/07/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 6600-851 | WI | N | Allopathic & Osteopathic Physicians | Dermatology | 207N00000X | 70147 | WI | Y | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.