Provider Demographics
NPI:1063449072
Name:TEDFORD, SHAWN ERIK (PA-C)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:ERIK
Last Name:TEDFORD
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 CAMPBELL WAY STE 201
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310-3323
Mailing Address - Country:US
Mailing Address - Phone:360-377-1355
Mailing Address - Fax:
Practice Address - Street 1:1225 CAMPBELL WAY STE 201
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-3323
Practice Address - Country:US
Practice Address - Phone:360-377-1355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2007-0004363A00000X, 363AM0700X, 363AS0400X
WAPA10003756363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA205198OtherLABOR & INDUSTRIES
WA1001498Medicaid
8918TEOtherREGENCE BLUESHIELD
WA8942304OtherCRIME VICTIMS COMP
P00330803OtherRAILROAD MEDICARE
P00330803OtherRAILROAD MEDICARE
8918TEOtherREGENCE BLUESHIELD
WAG8861421Medicare PIN
WAG8858251Medicare PIN
P00330803OtherRAILROAD MEDICARE