Provider Demographics
NPI:1902870637
Name:CUSTER, SHANON L (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANON
Middle Name:L
Last Name:CUSTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHANON
Other - Middle Name:L
Other - Last Name:SCHOENTHALER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2214 CANTERBURY DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:HAYS
Mailing Address - State:KS
Mailing Address - Zip Code:67601-2375
Mailing Address - Country:US
Mailing Address - Phone:785-623-2312
Mailing Address - Fax:785-623-2323
Practice Address - Street 1:2214 CANTERBURY DR
Practice Address - Street 2:SUITE 202
Practice Address - City:HAYS
Practice Address - State:KS
Practice Address - Zip Code:67601-2375
Practice Address - Country:US
Practice Address - Phone:785-623-2312
Practice Address - Fax:785-623-2323
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-30345207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200335110AMedicaid
KSI14841Medicare UPIN
KS104981Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE #