Healthcare Provider Details

I. General information

NPI: 1023078045
Provider Name (Legal Business Name): SHANNON R STAKER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 W 300 N 75-3
ROOSEVELT UT
84066
US

IV. Provider business mailing address

210 W 300 N 75-3
ROOSEVELT UT
84066
US

V. Phone/Fax

Practice location:
  • Phone: 435-722-3971
  • Fax: 435-722-6104
Mailing address:
  • Phone: 435-722-3971
  • Fax: 435-722-6104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number49110641205
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierD3849
Identifier TypeMEDICAID
Identifier StateUT
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: