Provider Demographics
NPI:1093808891
Name:SHELLEY, PETER B (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:B
Last Name:SHELLEY
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 1:32123 1ST AVE S
Mailing Address - Street 2:SUITE A-3
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-5721
Mailing Address - Country:US
Mailing Address - Phone:253-838-6272
Mailing Address - Fax:253-874-2690
Practice Address - Street 1:32123 1ST AVE S
Practice Address - Street 2:SUITE A-3
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-5721
Practice Address - Country:US
Practice Address - Phone:253-838-6272
Practice Address - Fax:253-874-2690
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00018850174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1748805Medicaid
WAA05608Medicare UPIN