Basic Information
| Provider Information | |||||||||
| NPI: | 1518144773 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAHAN | ||||||||
| FirstName: | JARED | ||||||||
| MiddleName: | TY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60112 | ||||||||
| Address2: | |||||||||
| City: | CORPUS CHRISTI | ||||||||
| State: | TX | ||||||||
| PostalCode: | 784660112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3618842904 | ||||||||
| FaxNumber: | 3618841912 | ||||||||
| Practice Location | |||||||||
| Address1: | 14254 SPID DR STE 207 | ||||||||
| Address2: | |||||||||
| City: | CORPUS CHRISTI | ||||||||
| State: | TX | ||||||||
| PostalCode: | 784186278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3615894068 | ||||||||
| FaxNumber: | 3615894079 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2008 | ||||||||
| LastUpdateDate: | 03/21/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD00049280 | WA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 04-35033 | KS | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 30234 | OK | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | P9000 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200717140 | 05 | KS | MEDICAID |