Provider Demographics
NPI:1588758338
Name:STAKER, SHANE A (DC)
Entity type:Individual
Prefix:DR
First Name:SHANE
Middle Name:A
Last Name:STAKER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 459
Mailing Address - Street 2:
Mailing Address - City:WEST BRANCH
Mailing Address - State:IA
Mailing Address - Zip Code:52358
Mailing Address - Country:US
Mailing Address - Phone:319-643-5194
Mailing Address - Fax:
Practice Address - Street 1:323 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:WEST BRANCH
Practice Address - State:IA
Practice Address - Zip Code:52358
Practice Address - Country:US
Practice Address - Phone:319-643-5194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06621111N00000X
CADC28913111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0473165Medicaid
IAU89963Medicare UPIN
IAI11729Medicare ID - Type UnspecifiedINDIVIDUAL
IA0473165Medicaid