Provider Demographics
NPI:1467457564
Name:SHELTON, THOMAS N (DO)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:N
Last Name:SHELTON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15214 CANYON RD E STE 120
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98375-7472
Mailing Address - Country:US
Mailing Address - Phone:253-539-4200
Mailing Address - Fax:253-539-6005
Practice Address - Street 1:15214 CANYON RD E STE 120
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98375-7472
Practice Address - Country:US
Practice Address - Phone:253-539-4200
Practice Address - Fax:253-539-6005
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00001078207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0263650OtherSTATE L&I
WA911465840OtherFEDERAL TAX ID
WA0267959OtherSTATE L&I
WA0263658OtherSTATE L&I
WA0263633OtherSTATE L&I
WA0263655OtherSTATE L&I
WA0263636OtherSTATE L&I
WA0263630OtherSTATE L&I
WA0263632OtherSTATE L&I
WA0263638OtherSTATE L&I
WA0255578OtherSTATE L&I
WA0263641OtherSTATE L&I
WA0263642OtherSTATE L&I
WA0268165OtherSTATE L&I
WA5840SHOtherREGENCE BLUE SHIELD RIDER
WAG8891934Medicare PIN
WAG8891932Medicare PIN
WA0263658OtherSTATE L&I
WA0263636OtherSTATE L&I
WAE39876Medicare UPIN
WAG8891933Medicare PIN
WAG8891939Medicare PIN
WAG8861997Medicare PIN
WA911465840OtherFEDERAL TAX ID
WA0268165OtherSTATE L&I
WAG8891935Medicare PIN