Provider Demographics
NPI:1902972441
Name:WATKINS, SHANNON (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
Last Name:WATKINS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:SHANNON
Other - Middle Name:RENEE
Other - Last Name:WRIGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1065 ASHLEY ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-3400
Mailing Address - Country:US
Mailing Address - Phone:270-781-5111
Mailing Address - Fax:270-780-0478
Practice Address - Street 1:1065 ASHLEY ST
Practice Address - Street 2:SUITE 200
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-3400
Practice Address - Country:US
Practice Address - Phone:270-781-5111
Practice Address - Fax:270-780-0478
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 97022207N00000X
KY41396207N00000X
TN45270207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100046110Medicaid
TN3042182Medicare PIN
KY7100046110Medicaid