Provider Demographics
NPI:1639282148
Name:FIFE, SHANNON C (DO)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:C
Last Name:FIFE
Suffix:
Gender:F
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:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:
Practice Address - Street 1:940 ROYAL AVE
Practice Address - Street 2:SUITE 350
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6193
Practice Address - Country:US
Practice Address - Phone:541-732-7460
Practice Address - Fax:541-732-7461
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO26604207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR005986Medicaid
OR005986Medicaid