Provider Demographics
NPI:1598053498
Name:GIFFORD, SHAWNA C (MD)
Entity Type:Individual
Prefix:
First Name:SHAWNA
Middle Name:C
Last Name:GIFFORD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 W 10TH ST
Mailing Address - Street 2:ATTN: EXECUTIVE DIRECTOR OF PHYSICIAN CLINCS
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-2905
Mailing Address - Country:US
Mailing Address - Phone:573-364-9000
Mailing Address - Fax:573-426-2108
Practice Address - Street 1:1050 W 10TH ST
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-2905
Practice Address - Country:US
Practice Address - Phone:573-364-9000
Practice Address - Fax:573-426-3643
Is Sole Proprietor?:No
Enumeration Date:2011-07-13
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014008977208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics