Provider Demographics
NPI:1164422911
Name:SISTRUNK, SHYRL
Entity Type:Individual
Prefix:
First Name:SHYRL
Middle Name:
Last Name:SISTRUNK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 PENNSYLVANIA AVE SE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20003-4346
Mailing Address - Country:US
Mailing Address - Phone:202-546-4504
Mailing Address - Fax:
Practice Address - Street 1:915 HALF STREET, SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20003
Practice Address - Country:US
Practice Address - Phone:202-546-4504
Practice Address - Fax:866-639-4761
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC20757207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F97980Medicare UPIN
DC018743G93Medicare PIN