Provider Demographics
NPI:1649220302
Name:ENGEL, SHANNON ALAN (DPM)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:ALAN
Last Name:ENGEL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5202 FARAON ST STE A
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-3840
Mailing Address - Country:US
Mailing Address - Phone:816-271-1067
Mailing Address - Fax:816-271-1071
Practice Address - Street 1:5202 FARAON ST.,
Practice Address - Street 2:STE. A
Practice Address - City:ST. JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-3480
Practice Address - Country:US
Practice Address - Phone:816-271-1067
Practice Address - Fax:816-271-1071
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2017-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00777213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200671880AMedicaid
IA37479OtherWELLMARK
MO1649220302Medicaid
IA37479OtherWELLMARK
IAI13026Medicare ID - Type Unspecified
MO701000069Medicare PIN