Provider Demographics
NPI:1831585538
Name:SHIELDS, MARICARMEN STOUT (MD)
Entity type:Individual
Prefix:
First Name:MARICARMEN
Middle Name:STOUT
Last Name:SHIELDS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARICARMEN
Other - Middle Name:
Other - Last Name:STOUT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:840 SE BISHOP BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163-5502
Mailing Address - Country:US
Mailing Address - Phone:509-332-6139
Mailing Address - Fax:509-332-6579
Practice Address - Street 1:1205 SE PROFESSIONAL MALL BLVD STE 104
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-5423
Practice Address - Country:US
Practice Address - Phone:509-332-2605
Practice Address - Fax:509-334-5754
Is Sole Proprietor?:No
Enumeration Date:2015-04-09
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60853005208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics