Basic Information
| Provider Information | |||||||||
| NPI: | 1093787616 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BACKSTROM | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 86370 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571186370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053227510 | ||||||||
| FaxNumber: | 6053226475 | ||||||||
| Practice Location | |||||||||
| Address1: | 1417 S. CLIFF AVE. | ||||||||
| Address2: | STE. 100 | ||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571051063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053228937 | ||||||||
| FaxNumber: | 6053228938 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2006 | ||||||||
| LastUpdateDate: | 10/10/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP1700X | CP000442 | SD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Perinatal |
ID Information
| ID | Type | State | Issuer | Description | 2387949 | 01 | SD | ARAZ/ AMERICA'S PPO | OTHER | 400070600 | 05 | MN | MEDICAID | 83G56BE | 01 | MN | CC SYSTEMS/ BLUE PLUS | OTHER | 283761045259 | 01 | SD | PREFERRED ONE | OTHER | 9244760 | 01 | SD | DAKOTACARE | OTHER | HP55697 | 01 | SD | HEALTHPARTNERS | OTHER | 0407827 | 01 | SD | MEDICA | OTHER | 0503706 | 05 | IA | MEDICAID | 57105AD05 | 01 | SD | WPS TRICARE | OTHER | 6828300 | 05 | SD | MEDICAID | 10025040700 | 05 | NE | MEDICAID | 248007 | 01 | SD | BLUE CROSS | OTHER | 370624200 | 01 | SD | DEPT OF LABOR | OTHER | 6828302 | 05 | SD | MEDICAID | 83G56BE | 01 | MN | BLUE CROSS | OTHER | 924114229808 | 01 | MN | PRIMEWEST | OTHER | 248007 | 01 | SD | MIDLANDS CHOICE | OTHER |