Provider Demographics
NPI:1265455679
Name:TRELSTAD, SHAWN VANDEUSEN (MD)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:VANDEUSEN
Last Name:TRELSTAD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHAWN
Other - Middle Name:K
Other - Last Name:VANDEUSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:825 NE MULTNOMAH ST
Mailing Address - Street 2:SUITE 1155
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2135
Mailing Address - Country:US
Mailing Address - Phone:503-464-9034
Mailing Address - Fax:
Practice Address - Street 1:2211 NE 139TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-2742
Practice Address - Country:US
Practice Address - Phone:360-487-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00044562207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8388084Medicaid
WA8854383Medicare UPIN
WA8388084Medicaid