Provider Demographics
NPI:1447279047
Name:ROBERTS, SHANNON A (DO)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:A
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:DO
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 910670
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40591-0670
Mailing Address - Country:US
Mailing Address - Phone:859-971-4685
Mailing Address - Fax:859-971-4602
Practice Address - Street 1:3084 LAKECREST CIR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40513-1706
Practice Address - Country:US
Practice Address - Phone:859-219-6440
Practice Address - Fax:859-219-6449
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02918207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64108400Medicaid
KYK060070Medicare PIN
KYI40388Medicare UPIN