Healthcare Provider Details

I. General information

NPI: 1932356078
Provider Name (Legal Business Name): SHAUNDA MARIE RODRIGUEZ D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2008
Last Update Date: 07/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1947 N FOUNDERS CIR
WICHITA KS
67206-3548
US

IV. Provider business mailing address

PO BOX 8035
WICHITA KS
67208-0035
US

V. Phone/Fax

Practice location:
  • Phone: 316-613-4680
  • Fax: 316-613-4906
Mailing address:
  • Phone: 316-689-9135
  • Fax: 316-689-9769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License NumberOTO12165
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number931
License Number StateNE
# 3
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number05-38208
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: