Provider Demographics
NPI:1497788129
Name:SHAUGER, KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:SHAUGER
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 1:6567 E CARONDELET DR STE 305
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710-6160
Mailing Address - Country:US
Mailing Address - Phone:520-881-8400
Mailing Address - Fax:
Practice Address - Street 1:6567 E CARONDELET DR STE 305
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-6160
Practice Address - Country:US
Practice Address - Phone:520-881-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2001014962084N0400X
AZ580902084N0400X
CT694962084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN01499Medicaid
NC8913082Medicaid
SCN01499Medicaid
NC8913082Medicaid
NCP00417367Medicare PIN
NC2000057BMedicare PIN