Provider Demographics
NPI:1760588099
Name:SHIVELEY, MATTHEW JAMES (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JAMES
Last Name:SHIVELEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1313 BROADWAY PLAZA
Mailing Address - Street 2:STE 200
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-3400
Mailing Address - Country:US
Mailing Address - Phone:253-426-6306
Mailing Address - Fax:253-426-6344
Practice Address - Street 1:1313 BROADWAY PLAZA
Practice Address - Street 2:STE 200
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-3400
Practice Address - Country:US
Practice Address - Phone:253-426-6306
Practice Address - Fax:253-426-6344
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00046533207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0242294OtherSTATE L&I
WA0242294OtherSTATE L&I
WAG8876972Medicare PIN