Provider Demographics
NPI:1447320510
Name:MUDERLAK, SHANNON SARAH (MD)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:SARAH
Last Name:MUDERLAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9252 N GREEN BAY RD
Mailing Address - Street 2:
Mailing Address - City:BROWN DEER
Mailing Address - State:WI
Mailing Address - Zip Code:53209-1104
Mailing Address - Country:US
Mailing Address - Phone:414-527-7500
Mailing Address - Fax:414-365-6320
Practice Address - Street 1:9252 N GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:BROWN DEER
Practice Address - State:WI
Practice Address - Zip Code:53209-1104
Practice Address - Country:US
Practice Address - Phone:414-527-7500
Practice Address - Fax:414-365-6320
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI47211207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine