Provider Demographics
NPI:1093713836
Name:SHEA, DONALD JEREMIAH JR (LMP)
Entity Type:Individual
Prefix:MR
First Name:DONALD
Middle Name:JEREMIAH
Last Name:SHEA
Suffix:JR
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2839 GRANT ST
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-2607
Mailing Address - Country:US
Mailing Address - Phone:360-671-4489
Mailing Address - Fax:360-671-4489
Practice Address - Street 1:2839 GRANT ST
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-2607
Practice Address - Country:US
Practice Address - Phone:360-671-4489
Practice Address - Fax:360-671-4489
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00001617225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA08193OtherLABOR AND INDUSTRIES