Individual
DR. MARY KELLY SHANAHAN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
1154 EMERALD BAY RD, SOUTH LAKE TAHOE, CA 96150-6288
(530) 542-4961
(530) 542-4964
Mailing address
1154 EMERALD BAY RD, SOUTH LAKE TAHOE, CA 96150-6288
(530) 542-4961
(530) 542-4964
Taxonomy
Speciality
Code
Description
License number
State
207V00000X
Obstetrics & Gynecology Physician
7055
NV
207V00000X
Obstetrics & Gynecology Physician
Primary
G78582
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1588661359
—
CA
05
—
1588661359
—
NV
Enumeration date
07/07/2005
Last updated
04/03/2015
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