Provider Demographics
NPI:1730270596
Name:KOEHN, SHANDA RENAE (DC)
Entity type:Individual
Prefix:MRS
First Name:SHANDA
Middle Name:RENAE
Last Name:KOEHN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:MS
Other - First Name:SHANDA
Other - Middle Name:RENAE
Other - Last Name:BARNES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:2601 CENTRAL AVE
Mailing Address - Street 2:SUITE 22
Mailing Address - City:DODGE CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67801-6200
Mailing Address - Country:US
Mailing Address - Phone:620-227-9902
Mailing Address - Fax:620-227-9932
Practice Address - Street 1:2601 CENTRAL AVE
Practice Address - Street 2:SUITE 22
Practice Address - City:DODGE CITY
Practice Address - State:KS
Practice Address - Zip Code:67801-6200
Practice Address - Country:US
Practice Address - Phone:620-227-9902
Practice Address - Fax:620-227-9932
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS01-04848111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSP00116509OtherRAILROAD MC ID #
KS062037OtherINDIVIDUAL BC/MC ID #
KS660055Medicare UPIN
KS062037Medicare ID - Type UnspecifiedINDIVIDUAL PROVIDER ID #