Provider Demographics
NPI:1407008113
Name:BALES, SHANNON RYLEE (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:RYLEE
Last Name:BALES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:RYLEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3900 S ZINTEL WAY
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99337-5092
Mailing Address - Country:US
Mailing Address - Phone:509-942-3627
Mailing Address - Fax:509-942-2268
Practice Address - Street 1:1100 GOETHALS DR FL 1
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-3300
Practice Address - Country:US
Practice Address - Phone:509-942-3288
Practice Address - Fax:509-946-9389
Is Sole Proprietor?:No
Enumeration Date:2008-10-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA101730207R00000X
WAMD60249292207RE0101X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMD60249292OtherWA MEDICAL LICENSE
WA2017649Medicaid
WA0289445OtherLABOR & INDUSTRIES
WA0289445OtherLABOR & INDUSTRIES
WA2017649Medicaid