Age Reversal Technologies

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

License

15-00115 Issued in KS

Legal business name

AGE REVERSAL TECHNOLOGIES

Practice address

2600 N Woodlawn Blvd
Wichita, KS 67220-2729

Phone

(316) 640-6253

Fax

(316) 858-2523

NPI assigned

Jan 5, 2011

Last updated

Sep 30, 2011By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Michael N Shaw, P.A.

Title

Owner/President

Phone

(316) 640-6253

Specialties & licenses 2

Addresses

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1294185600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1317340800000",
    "number": "1841594892",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2600 N WOODLAWN BLVD",
            "city": "WICHITA",
            "state": "KS",
            "postal_code": "672202729",
            "telephone_number": "316-640-6253",
            "fax_number": "316-858-2523"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2600 N WOODLAWN BLVD",
            "city": "WICHITA",
            "state": "KS",
            "postal_code": "672202729",
            "telephone_number": "316-640-6253",
            "fax_number": "316-858-2523"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "AGE REVERSAL TECHNOLOGIES",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-01-05",
        "last_updated": "2011-09-30",
        "status": "A",
        "authorized_official_last_name": "SHAW",
        "authorized_official_first_name": "MICHAEL",
        "authorized_official_middle_name": "N",
        "authorized_official_title_or_position": "OWNER/PRESIDENT",
        "authorized_official_telephone_number": "316-640-6253",
        "authorized_official_credential": "P.A."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "KS",
            "license": "15-00115",
            "primary": true
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "KS",
            "license": "15-00115",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Komi N Agbodzie, CRNA
• Antoine L. Agnew, LSCSW
• Delani Agnew, LMSW
• Jennifer Rose Agnew
• Mark Agpoon, CRNA
• Robin L Agpoon, OD

• Family Medicine Physician in Wichita, KS
• Providers in Wichita, KS by specialty
• Family Medicine Physician in Kansas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 30, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.