Provider Demographics
NPI:1508417577
Name:COLO, SHANTI
Entity type:Individual
Prefix:
First Name:SHANTI
Middle Name:
Last Name:COLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1608 S J ST
Mailing Address - Street 2:FL 1
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4930
Mailing Address - Country:US
Mailing Address - Phone:253-274-7501
Mailing Address - Fax:253-274-7991
Practice Address - Street 1:406 WELCH ST
Practice Address - Street 2:
Practice Address - City:SILVERTON
Practice Address - State:OR
Practice Address - Zip Code:97381-1934
Practice Address - Country:US
Practice Address - Phone:503-364-3787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-21
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60939595163W00000X
OR201809217163W00000X
WAAP61161569367A00000X
OR202006152NP-PP367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500781877Medicaid