Provider Demographics
NPI:1780066639
Name:RIRIE, SHANE (PA-C)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:RIRIE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 N EPHRATA AVE
Mailing Address - Street 2:
Mailing Address - City:CONNELL
Mailing Address - State:WA
Mailing Address - Zip Code:99326-9601
Mailing Address - Country:US
Mailing Address - Phone:509-543-5800
Mailing Address - Fax:
Practice Address - Street 1:1301 N EPHRATA AVE
Practice Address - Street 2:
Practice Address - City:CONNELL
Practice Address - State:WA
Practice Address - Zip Code:99326-9601
Practice Address - Country:US
Practice Address - Phone:509-543-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-26
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60566156363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant