Provider Demographics
NPI:1083819692
Name:COLEMAN, SHANE M (MD, MPH)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:M
Last Name:COLEMAN
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 SW THEATER DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-3509
Mailing Address - Country:US
Mailing Address - Phone:206-310-9452
Mailing Address - Fax:
Practice Address - Street 1:2600 NE NEFF RD
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-6337
Practice Address - Country:US
Practice Address - Phone:541-706-4800
Practice Address - Fax:541-706-4806
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK77282084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA246201OtherMEDICAL LICENSE
WA1083819Medicaid
MA232258OtherMEDICAL TRAINING/LIMITED LICENSE
AK6810OtherMEDICAL LICENSE - TEMP
WAMD60212882OtherMEDICAL LICENSE
AK7728OtherMEDICAL LICENS
AKMD00372OtherALASKA MEDICAID PROVIDER NUMBER
WA1083819Medicaid