Provider Demographics
NPI:1275615494
Name:SHRADER, DAVID L (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:L
Last Name:SHRADER
Suffix:
Gender:M
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:P.O. BOX 579
Mailing Address - Street 2:
Mailing Address - City:AFTON
Mailing Address - State:WY
Mailing Address - Zip Code:83110-0579
Mailing Address - Country:US
Mailing Address - Phone:307-885-5852
Mailing Address - Fax:307-885-5889
Practice Address - Street 1:110 HOSPITAL LANE
Practice Address - Street 2:
Practice Address - City:AFTON
Practice Address - State:WY
Practice Address - Zip Code:83110
Practice Address - Country:US
Practice Address - Phone:307-855-5852
Practice Address - Fax:208-529-0359
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM3691174400000X
WYTL802207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1111862Medicare ID - Type Unspecified
IDC47815Medicare UPIN