Provider Demographics
NPI:1508164377
Name:TOLBERT, SHAUN DAVID (DNP, PMHNP-BC)
Entity Type:Individual
Prefix:DR
First Name:SHAUN
Middle Name:DAVID
Last Name:TOLBERT
Suffix:
Gender:M
Credentials:DNP, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:922 NW CIR BLVD STE 160
Mailing Address - Street 2:PMB 268
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-1180
Mailing Address - Country:US
Mailing Address - Phone:205-908-8142
Mailing Address - Fax:
Practice Address - Street 1:530 NW 27TH ST
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-5223
Practice Address - Country:US
Practice Address - Phone:541-766-6835
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201906152NP-PP363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR363LP0808XOtherTAXONOMY
OR363LP0808XOtherTAXONOMY