Basic Information
| Provider Information | |||||||||
| NPI: | 1982715777 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAKERIN | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5700 BOTTINEAU BLVD | ||||||||
| Address2: | #210 | ||||||||
| City: | CRYSTAL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554293183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635877000 | ||||||||
| FaxNumber: | 7635877015 | ||||||||
| Practice Location | |||||||||
| Address1: | 5700 BOTTINEAU BLVD | ||||||||
| Address2: | #210 | ||||||||
| City: | CRYSTAL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554293183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635877000 | ||||||||
| FaxNumber: | 7635877015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 06/18/2014 | ||||||||
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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 | 207V00000X | 34679 | MN | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 998563800 | 05 | MN | MEDICAID |