Basic Information
| Provider Information | |||||||||
| NPI: | 1821053091 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHETLAR | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | M | ||||||||
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| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1410 E IRON AVE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | SALINA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 674013284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888786881 | ||||||||
| FaxNumber: | 7858250644 | ||||||||
| Practice Location | |||||||||
| Address1: | 1410 E IRON AVE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | SALINA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 674013284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888786881 | ||||||||
| FaxNumber: | 3166343065 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2006 | ||||||||
| LastUpdateDate: | 06/04/2016 | ||||||||
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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 | 0524233 | KS | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100162320E | 05 | KS | MEDICAID |