Provider Demographics
NPI:1124412184
Name:KHADEMI, SHAWN B (DPM)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:B
Last Name:KHADEMI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 TALBOT RD S STE 102
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-6238
Mailing Address - Country:US
Mailing Address - Phone:425-277-3668
Mailing Address - Fax:
Practice Address - Street 1:4300 TALBOT RD S STE 102
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-6238
Practice Address - Country:US
Practice Address - Phone:425-277-3668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-26
Last Update Date:2021-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016005850213ES0103X
MA1348213ES0103X
WAPO61142698213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty