Provider Demographics
NPI:1205203239
Name:SHRADER, STEPHEN
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:SHRADER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2154 NW 204TH ST
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98177-2359
Mailing Address - Country:US
Mailing Address - Phone:206-719-0117
Mailing Address - Fax:
Practice Address - Street 1:2154 NW 204TH ST
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98177-2359
Practice Address - Country:US
Practice Address - Phone:206-719-0117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-25
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist