Provider Demographics
NPI:1710151238
Name:GATES, SHANNON D (MD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:D
Last Name:GATES
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 1:1344 WINTERGREEN LN NE UNIT 100
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98110-5147
Mailing Address - Country:US
Mailing Address - Phone:206-201-0488
Mailing Address - Fax:206-201-0490
Practice Address - Street 1:1344 WINTERGREEN LN NE STE 100
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98110-5118
Practice Address - Country:US
Practice Address - Phone:206-201-0488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-16
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA103930207P00000X
WAMD60612568207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2130389Medicaid