Provider Demographics
NPI:1609092964
Name:SHELTON FAMILY MEDICINE PLLC
Entity Type:Organization
Organization Name:SHELTON FAMILY MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:LANMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-426-2653
Mailing Address - Street 1:939 MOUNTAIN VIEW DRIVE
Mailing Address - Street 2:STE 100
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-4410
Mailing Address - Country:US
Mailing Address - Phone:360-426-2653
Mailing Address - Fax:360-427-7086
Practice Address - Street 1:939 MOUNTAIN VIEW DRIVE
Practice Address - Street 2:STE 100
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-4410
Practice Address - Country:US
Practice Address - Phone:360-426-2653
Practice Address - Fax:360-427-7086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601868919207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG000247600OtherMEDICARE ASSIGNED CLINIC NUMBER