1083788475 NPI number — MARTHA JANE SHANAHAN RD, CD

Table of content: MARTHA JANE SHANAHAN RD, CD (NPI 1083788475)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083788475 NPI number — MARTHA JANE SHANAHAN RD, CD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHANAHAN
Provider First Name:
MARTHA
Provider Middle Name:
JANE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RD, CD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
YARBROUGH
Provider Other First Name:
MARTHA
Provider Other Middle Name:
JANE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RD, CD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1083788475
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2372 FRANKLIN AVE E
Provider Second Line Business Mailing Address:
APT A
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98102-3330
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-399-0140
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
126 AUBURN AVE
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
AUBURN
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98002-5057
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-205-6808
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/20/2006

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: 133V00000X , with the licence number:  DI00001835 , 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)

  • Identifier: 8457459 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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