Provider Demographics
NPI:1356478762
Name:LOECK, SHANNON L (MD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:LOECK
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 1:1010 N KANSAS ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-3124
Mailing Address - Country:US
Mailing Address - Phone:316-293-2665
Mailing Address - Fax:
Practice Address - Street 1:1001 N MINNEAPOLIS ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-3127
Practice Address - Country:US
Practice Address - Phone:316-293-2647
Practice Address - Fax:855-476-0305
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS94-088902084P0800X
CT0001642255A2300X
KS04-430632084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS30004650390002Medicaid