Provider Demographics
NPI:1518144773
Name:SHAHAN, JARED TY (MD)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:TY
Last Name:SHAHAN
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:PO BOX 60112
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78466-0112
Mailing Address - Country:US
Mailing Address - Phone:361-884-2904
Mailing Address - Fax:361-884-1912
Practice Address - Street 1:14254 SPID DR STE 207
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78418-6278
Practice Address - Country:US
Practice Address - Phone:361-589-4068
Practice Address - Fax:361-589-4079
Is Sole Proprietor?:No
Enumeration Date:2008-01-29
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00049280207Q00000X
KS04-35033207Q00000X
OK30234207Q00000X
TXP9000207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200717140Medicaid