Provider Demographics
NPI:1790891521
Name:LOHSE, SHANDA RENEE (MD)
Entity Type:Individual
Prefix:
First Name:SHANDA
Middle Name:RENEE
Last Name:LOHSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHANDA
Other - Middle Name:RENEE
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1001 S KNIK GOOSE BAY RD
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-8083
Mailing Address - Country:US
Mailing Address - Phone:907-631-7803
Mailing Address - Fax:
Practice Address - Street 1:3380 C ST
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-3949
Practice Address - Country:US
Practice Address - Phone:907-717-4550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK5512207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD5039Medicaid