Basic Information
| Provider Information | |||||||||
| NPI: | 1609071158 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | SHAWN | ||||||||
| MiddleName: | IAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1947 N FOUNDERS CIR | ||||||||
| Address2: | WCGME | ||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672063548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166134930 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1947 N FOUNDERS CIR | ||||||||
| Address2: | WCGME | ||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672063548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166134930 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2007 | ||||||||
| LastUpdateDate: | 12/01/2014 | ||||||||
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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 | 207L00000X | 04-33385 | KS | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207R00000X | 04-33385 | KS | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200656050A | 05 | KS | MEDICAID |