1316915309 NPI number — MR. SHANE A. WALTER IDC

Table of content: MR. SHANE A. WALTER IDC (NPI 1316915309)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316915309 NPI number — MR. SHANE A. WALTER IDC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALTER
Provider First Name:
SHANE
Provider Middle Name:
A.
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
IDC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316915309
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
790 NE SHOREWOOD CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POULSBO
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98370-8436
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-598-5312
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
BHC BANGOR, 2050 BARB ST
Provider Second Line Business Practice Location Address:
SUITE A, NAVAL SUBMARINE BASE BANGOR
Provider Business Practice Location Address City Name:
SILVERDALE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98315-2099
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-315-4356
Provider Business Practice Location Address Fax Number:
360-396-4247
Provider Enumeration Date:
03/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1710I1002X , with the licence number:  0I1002X171 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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