Individual
SHANNA RACHELLE VIDOR
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
5219 ST JOHN DRIVE, NETT LAKE, MN 55772-8232
(218) 757-3295
Mailing address
5219 ST JOHN DRIVE, NETT LAKE, MN 55772-8232
(218) 757-3295
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
55689
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1215229729
BCBS
MN
01
—
1215229729
MEDICA
—
05
—
1215229729
—
MN
01
—
P01105126
RAILROAD MEDICARE
MN
Enumeration date
05/03/2011
Last updated
06/18/2020
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