MEDICARE: SHANNON LYNN BACKSTROM CNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP1700X	Perinatal Nurse Practitioner	CP000442	SD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2387949	OTHER	SD	ARAZ/ AMERICA'S PPO
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	83G56BE	OTHER	MN	CC SYSTEMS/ BLUE PLUS
4	283761045259	OTHER	SD	PREFERRED ONE
5	9244760	OTHER	SD	DAKOTACARE
6	HP55697	OTHER	SD	HEALTHPARTNERS
7	0407827	OTHER	SD	MEDICA
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
9	57105AD05	OTHER	SD	WPS TRICARE
10	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
11	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
12	248007	OTHER	SD	BLUE CROSS
13	370624200	OTHER	SD	DEPT OF LABOR
14	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
15	83G56BE	OTHER	MN	BLUE CROSS
16	924114229808	OTHER	MN	PRIMEWEST
17	248007	OTHER	SD	MIDLANDS CHOICE

General Provider Information

NPI Number	:	1093787616
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON LYNN BACKSTROM CNP

Provider Business Mailing Address
First Line	:	PO BOX 86370
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57118-6370
Country	:	US
Telephone Number	:	605-322-7510
Fax Number	:	605-322-6475

Provider Business Practice Location Address
First Line	:	1417 S. CLIFF AVE.
Second Line	:	STE. 100
City	:	SIOUX FALLS
State	:	SD
Zip	:	57105-1063
Country	:	US
Telephone Number	:	605-322-8937
Fax Number	:	605-322-8938

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/07/2006
Last Update Date	:	10/10/2018

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