Provider Demographics
NPI:1902060759
Name:BASENER, SHAUNA M (DO)
Entity Type:Individual
Prefix:DR
First Name:SHAUNA
Middle Name:M
Last Name:BASENER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:SHAUNA
Other - Middle Name:M
Other - Last Name:MATLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1215 DUFF AVENUE
Mailing Address - Street 2:
Mailing Address - City:AMES
Mailing Address - State:IA
Mailing Address - Zip Code:50010-3014
Mailing Address - Country:US
Mailing Address - Phone:515-239-4432
Mailing Address - Fax:515-239-4754
Practice Address - Street 1:1215 DUFF AVENUE
Practice Address - Street 2:
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50010-3014
Practice Address - Country:US
Practice Address - Phone:515-239-4432
Practice Address - Fax:515-239-4754
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADO-04201207R00000X
MN106624207R00000X
IA4201207R00000X
MI5101017648207R00000X
IA04201207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN110016091Medicare PIN
IA1902060759Medicaid