Healthcare Provider Details

I. General information

NPI: 1992159792
Provider Name (Legal Business Name): STEPHANIE SHIN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2016
Last Update Date: 06/25/2020
Certification Date: 06/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS PL
SAINT LOUIS MO
63110-1002
US

IV. Provider business mailing address

8130 ROXBURGH DR APT 2E
SAINT LOUIS MO
63105-2435
US

V. Phone/Fax

Practice location:
  • Phone: 314-565-1247
  • Fax:
Mailing address:
  • Phone: 314-565-1247
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License Number2020014035
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: