Provider Demographics
NPI:1326236498
Name:HAUPT, SHANE (LMP)
Entity Type:Individual
Prefix:MR
First Name:SHANE
Middle Name:
Last Name:HAUPT
Suffix:
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 1:3021 NE 72ND DR STE 9-63
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-7300
Mailing Address - Country:US
Mailing Address - Phone:360-513-2654
Mailing Address - Fax:
Practice Address - Street 1:11701 NE 95TH ST STE C
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98682-2318
Practice Address - Country:US
Practice Address - Phone:360-513-2654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-13
Last Update Date:2007-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00020575174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist