Healthcare Provider Details

I. General information

NPI: 1194801019
Provider Name (Legal Business Name): SHANNON A CARRO OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 01/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 S BROADWAY ST
WICHITA KS
67202-4304
US

IV. Provider business mailing address

1655 S GEORGETOWN ST
WICHITA KS
67218-4140
US

V. Phone/Fax

Practice location:
  • Phone: 316-267-5437
  • Fax: 316-267-5444
Mailing address:
  • Phone: 316-685-0400
  • Fax: 316-612-0839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License NumberT00720
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: