Provider Demographics
NPI:1083601264
Name:PRYOR, SHIRLEY M (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:SHIRLEY
Middle Name:M
Last Name:PRYOR
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:176 1ST AVE N
Mailing Address - Street 2:PO DRAWER N
Mailing Address - City:ILWACO
Mailing Address - State:WA
Mailing Address - Zip Code:98624
Mailing Address - Country:US
Mailing Address - Phone:360-642-3747
Mailing Address - Fax:360-642-3361
Practice Address - Street 1:176 1ST AVE N
Practice Address - Street 2:PO DRAWER N
Practice Address - City:ILWACO
Practice Address - State:WA
Practice Address - Zip Code:98624
Practice Address - Country:US
Practice Address - Phone:360-642-3747
Practice Address - Fax:360-642-3361
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30003770363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9616582Medicaid
WAPR8034OtherBCBS
S20149Medicare ID - Type Unspecified
WA9616582Medicaid