Provider Demographics
NPI:1275672529
Name:KANEASTER, SHANNON KYLE (MD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:KYLE
Last Name:KANEASTER
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 1:3033 NW 63RD ST
Mailing Address - Street 2:SUITE 152
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116-3634
Mailing Address - Country:US
Mailing Address - Phone:405-755-6651
Mailing Address - Fax:405-607-3559
Practice Address - Street 1:5701 N PORTLAND AVE
Practice Address - Street 2:SUITE 305
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-1678
Practice Address - Country:US
Practice Address - Phone:405-604-4475
Practice Address - Fax:405-604-4480
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK22929207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200172670AMedicaid
OKOK401456Medicare PIN