Provider Demographics
NPI:1669442877
Name:SHORTT, SANDRA (MD)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:
Last Name:SHORTT
Suffix:
Gender:F
Credentials:MD
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 5127
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-5127
Mailing Address - Country:US
Mailing Address - Phone:425-258-3900
Mailing Address - Fax:
Practice Address - Street 1:3901 HOYT AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4918
Practice Address - Country:US
Practice Address - Phone:425-339-5420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301049061207R00000X
WAMD00021927207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0B56065004OtherMEDICARE PART B
MI4254388Medicaid
MISS049061OtherHEALTH PLUS AND BCBS
WA2037672Medicaid
MIF75196Medicare UPIN
MI4254388Medicaid