Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 2014019429 | MO |
Y | 207QA0401X | Family Doctor - Addiction Medicine | 1558776229 | MO |
NPI | 1558776229 |
---|---|
Provider Name | Shawn Stranckmeyer |
First Address | Springfield, MO 65807-5233 |
Second Address | Las Vegas, NV 89113-1981 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/06/2014 |
Last Update Date | 28/02/2020 |