Provider Demographics
NPI:1225180698
Name:SON, SHANE R (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:R
Last Name:SON
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:PO BOX 12389
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98508-2389
Mailing Address - Country:US
Mailing Address - Phone:360-528-2100
Mailing Address - Fax:360-528-2104
Practice Address - Street 1:404 BLACK HILLS LN SW STE D
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-8148
Practice Address - Country:US
Practice Address - Phone:360-528-2100
Practice Address - Fax:360-528-2104
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00041776207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP00848649OtherRAILROAD MEDICARE
WA1025053Medicaid
WAP00848649OtherRAILROAD MEDICARE
WA1025053Medicaid