Provider Demographics
NPI:1588620793
Name:SNIDER, SHAWN (NP)
Entity Type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:
Last Name:SNIDER
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 TANGLEFOOT LN
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-1605
Mailing Address - Country:US
Mailing Address - Phone:309-285-8212
Mailing Address - Fax:888-660-9460
Practice Address - Street 1:880 TANGLEFOOT LN
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-1605
Practice Address - Country:US
Practice Address - Phone:309-285-8212
Practice Address - Fax:888-660-9460
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209005824363L00000X
IAA-128168363LF0000X
CA23734363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK24000Medicare ID - Type Unspecified
ILQ60743Medicare UPIN