Individual
SHANNON FOURTNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
8203 MAIN ST STE 14, WILLIAMSVILLE, NY 14221-6051
(585) 201-7112
(585) 201-7128
Mailing address
8203 MAIN ST STE 14, WILLIAMSVILLE, NY 14221-6051
(585) 201-7112
(585) 201-7128
Taxonomy
Speciality
Code
Description
License number
State
2080P0205X
Pediatric Endocrinology Physician
Primary
236427
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00027224401
UNIVERA
—
01
—
000528154001
BC/BS
—
05
—
02657463
—
NY
01
—
050805000017
FIDELIS
—
01
—
1019564320001
PA MEDICAID
—
01
—
1212950
IHA
—
Enumeration date
10/21/2006
Last updated
03/07/2025
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