Healthcare Provider Details

I. General information

NPI: 1235802075
Provider Name (Legal Business Name): SHANNON MARIE BAUMAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2021
Last Update Date: 07/28/2021
Certification Date: 07/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 GRAND AVE
WEST DES MOINES IA
50266-5357
US

IV. Provider business mailing address

500 S BLUESTONE WAY
WEST DES MOINES IA
50266-8705
US

V. Phone/Fax

Practice location:
  • Phone: 515-440-4820
  • Fax:
Mailing address:
  • Phone: 515-300-7010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberMD-47914
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: