1093787616 NPI number — SHANNON LYNN BACKSTROM CNP

Table of content: MILISSA K SHORT FNP-BC (NPI 1003089905)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093787616 NPI number — SHANNON LYNN BACKSTROM CNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BACKSTROM
Provider First Name:
SHANNON
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNP
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:
1093787616
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/10/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 86370
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIOUX FALLS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57118-6370
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-322-7510
Provider Business Mailing Address Fax Number:
605-322-6475

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1417 S. CLIFF AVE.
Provider Second Line Business Practice Location Address:
STE. 100
Provider Business Practice Location Address City Name:
SIOUX FALLS
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57105-1063
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-322-8937
Provider Business Practice Location Address Fax Number:
605-322-8938
Provider Enumeration Date:
02/07/2006

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: 363LP1700X , with the licence number:  CP000442 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2387949 . This is a "ARAZ/ AMERICA'S PPO" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 400070600 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 83G56BE . This is a "CC SYSTEMS/ BLUE PLUS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 283761045259 . This is a "PREFERRED ONE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 9244760 . This is a "DAKOTACARE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: HP55697 . This is a "HEALTHPARTNERS" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 0407827 . This is a "MEDICA" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 0503706 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 57105AD05 . This is a "WPS TRICARE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 6828300 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10025040700 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 248007 . This is a "BLUE CROSS" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 370624200 . This is a "DEPT OF LABOR" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 6828302 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 83G56BE . This is a "BLUE CROSS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 924114229808 . This is a "PRIMEWEST" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 248007 . This is a "MIDLANDS CHOICE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".




Copyright © 2007-2026 www.npivalidator.com