Provider Demographics
NPI:1922038801
Name:SHACKELFORD, KRISTA E (MD)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:E
Last Name:SHACKELFORD
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 1:835 N HILLSIDE ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-4913
Mailing Address - Country:US
Mailing Address - Phone:316-685-4395
Mailing Address - Fax:316-685-1149
Practice Address - Street 1:835 N HILLSIDE ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-4913
Practice Address - Country:US
Practice Address - Phone:316-685-4395
Practice Address - Fax:316-685-1149
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01061838A207N00000X
KS0432039207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS106571Medicare PIN