=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447969506
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RYAN SHACKELFORD MD, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2022
-----------------------------------------------------
Last Update Date | 11/17/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1525 S OWYHEE ST
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83705-6014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-297-3698
-----------------------------------------------------
Fax | 208-561-8051
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1525 S OWYHEE ST
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83705-6014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-297-3698
-----------------------------------------------------
Fax | 208-561-8051
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHIATRIST
-----------------------------------------------------
Name | JAMES RYAN SHACKELFORD
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 208-297-3698
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------