Basic Information
| Provider Information | |||||||||
| NPI: | 1710956727 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHANKS | ||||||||
| FirstName: | CANDACE | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FUNK | ||||||||
| OtherFirstName: | CANDACE | ||||||||
| OtherMiddleName: | M | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 865 LINCOLN RD | ||||||||
| Address2: | STE L10 | ||||||||
| City: | BETTENDORF | ||||||||
| State: | IA | ||||||||
| PostalCode: | 527224190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5633559191 | ||||||||
| FaxNumber: | 5633553419 | ||||||||
| Practice Location | |||||||||
| Address1: | 1008 11TH ST | ||||||||
| Address2: | |||||||||
| City: | DE WITT | ||||||||
| State: | IA | ||||||||
| PostalCode: | 527421210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5636599137 | ||||||||
| FaxNumber: | 5636599869 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 26904 | IA | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | IL | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2042713 | 05 | IA | MEDICAID | 06423 | 01 | IA | WELLMARK HEALTH PLAN | OTHER | IA0104 | 01 | JOHN DEERE PIN # | OTHER |