Organization
AGE REVERSAL TECHNOLOGIES
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MICHAEL N SHAW P.A. (OWNER/PRESIDENT)
(316) 640-6253
Entity
Organization
Contact information
Practice address
2600 N WOODLAWN BLVD, WICHITA, KS 67220-2729
(316) 640-6253
(316) 858-2523
Mailing address
2600 N WOODLAWN BLVD, WICHITA, KS 67220-2729
(316) 640-6253
(316) 858-2523
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
15-00115
KS
207R00000X
Internal Medicine Physician
15-00115
KS
Other
Enumeration date
01/05/2011
Last updated
09/30/2011
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