Basic Information
| Provider Information | |||||||||
| NPI: | 1396938916 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRODERSEN | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16528 E DESMET CT STE B3100 | ||||||||
| Address2: | |||||||||
| City: | SPOKANE VALLEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992163522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099449440 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 16528 E DESMET CT STE B3100 | ||||||||
| Address2: | |||||||||
| City: | SPOKANE VALLEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992163522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099449440 | ||||||||
| FaxNumber: | 5092277070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2007 | ||||||||
| LastUpdateDate: | 04/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD 60474752 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.