Provider Demographics
NPI:1073629150
Name:JOSHI, SHAUN K (MD)
Entity Type:Individual
Prefix:
First Name:SHAUN
Middle Name:K
Last Name:JOSHI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1986 W HAYDEN AVE
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-7412
Mailing Address - Country:US
Mailing Address - Phone:208-762-7760
Mailing Address - Fax:208-762-7740
Practice Address - Street 1:1986 W HAYDEN AVE
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-7412
Practice Address - Country:US
Practice Address - Phone:208-762-7760
Practice Address - Fax:208-762-7740
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00037068207RN0300X
IDM-8219207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7144785Medicaid
1370136OtherMEDICARE GROUP PTAN
ID8058994Medicaid
11003291OtherMEDICARE PTAN
ID8080036Medicaid
WA8239220Medicaid
WA8239220Medicaid