Provider Demographics
NPI:1043300270
Name:RILEY, SHANDA (MD)
Entity Type:Individual
Prefix:
First Name:SHANDA
Middle Name:
Last Name:RILEY
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 1:2951 N GOVERNEOUR ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-1760
Mailing Address - Country:US
Mailing Address - Phone:316-201-1133
Mailing Address - Fax:
Practice Address - Street 1:4401 WORNALL RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-3220
Practice Address - Country:US
Practice Address - Phone:816-932-2171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0431238207P00000X
MO2013026520207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200355370AMedicaid
KSP00260190Medicare PIN
KSI25268Medicare UPIN