Provider Demographics
NPI:1891772489
Name:KANNARR, SHANE R (OD)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:R
Last Name:KANNARR
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 W 29TH ST
Mailing Address - Street 2:SUITE G
Mailing Address - City:PITTSBURG
Mailing Address - State:KS
Mailing Address - Zip Code:66762-2696
Mailing Address - Country:US
Mailing Address - Phone:620-235-1737
Mailing Address - Fax:620-230-0358
Practice Address - Street 1:2521 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:KS
Practice Address - Zip Code:66762-2620
Practice Address - Country:US
Practice Address - Phone:620-235-1737
Practice Address - Fax:620-230-0358
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000160785152W00000X
KS1699152W00000X
AR2544152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS20036611ODMedicaid
A63D995Medicare PIN
U81481Medicare UPIN