Provider Demographics
NPI:1043292386
Name:LONGSHORE, SHANNON WRIGHT (MD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:WRIGHT
Last Name:LONGSHORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 751069
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:517 MOYE BLVD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-2849
Practice Address - Country:US
Practice Address - Phone:252-744-2832
Practice Address - Fax:252-744-3457
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2013-012842086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC180Y3OtherBCBSNC
NC1043292386Medicaid
NC180Y3OtherBCBSNC
NCNCE234AMedicare PIN