Provider Demographics
NPI:1396817524
Name:SHIN, HEAMIN T
Entity Type:Individual
Prefix:
First Name:HEAMIN
Middle Name:T
Last Name:SHIN
Suffix:
Gender:M
Credentials:
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 883
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97321-0323
Mailing Address - Country:US
Mailing Address - Phone:760-798-9477
Mailing Address - Fax:
Practice Address - Street 1:2875 NE STUCKI AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-5806
Practice Address - Country:US
Practice Address - Phone:800-813-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP192243213E00000X
CAE4545213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E45450Medicaid
CAE4545Medicare PIN
CA000E45452Medicare PIN
CA000E45450Medicaid
CA5160290001Medicare NSC
CA000E45450Medicare PIN
U95259Medicare UPIN