Provider Demographics
NPI:1053575506
Name:ARDOIN, SHANNON EDMONDS (MD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:EDMONDS
Last Name:ARDOIN
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 1:44 COLONY RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72227-2947
Mailing Address - Country:US
Mailing Address - Phone:501-960-2422
Mailing Address - Fax:
Practice Address - Street 1:44 COLONY RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72227-2947
Practice Address - Country:US
Practice Address - Phone:501-960-2422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-14
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-48192085R0202X
LAMD.0260962085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS512I300158Medicare PIN