1730284076 NPI number — SANDRA D. SHANABERGER P.A.-C.

Table of content: SANDRA D. SHANABERGER P.A.-C. (NPI 1730284076)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730284076 NPI number — SANDRA D. SHANABERGER P.A.-C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHANABERGER
Provider First Name:
SANDRA
Provider Middle Name:
D.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.A.-C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730284076
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/06/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4011 LELAND RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40207-2007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-699-9946
Provider Business Mailing Address Fax Number:
502-894-9991

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1009A N DUPONT SQ
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40207-4612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-894-9950
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  PA432 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 970021516 . This is a "RR MEDICARE PIN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: CB5773 . This is a "RR MEDICARE GROUP" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 37903705 . This is a "MEDICAID LAB GROUP" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 4000501 . This is a "MEDICARE LAB GROUP" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 95001640 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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