Provider Demographics
NPI:1962842260
Name:SHANLEY, PEBBLES DAKOTA (MD)
Entity Type:Individual
Prefix:
First Name:PEBBLES
Middle Name:DAKOTA
Last Name:SHANLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PEBBLES
Other - Middle Name:DAKOTA
Other - Last Name:CODY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 4105
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4105
Mailing Address - Country:US
Mailing Address - Phone:866-907-1068
Mailing Address - Fax:425-917-9141
Practice Address - Street 1:1201 E 36TH AVE
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4372
Practice Address - Country:US
Practice Address - Phone:907-562-9229
Practice Address - Fax:907-561-4806
Is Sole Proprietor?:No
Enumeration Date:2013-07-01
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK108535207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1597885Medicaid