Provider Demographics
NPI:1073260600
Name:WHITEHEAD, SHANE SUE
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:SUE
Last Name:WHITEHEAD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7015 25TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115-5811
Mailing Address - Country:US
Mailing Address - Phone:314-435-5954
Mailing Address - Fax:
Practice Address - Street 1:5801 SAND POINT WAY NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-2147
Practice Address - Country:US
Practice Address - Phone:206-987-4585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-03
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA61450508363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant