Provider Demographics
NPI:1881919918
Name:PETERSON, SHANE EMBER (MD)
Entity type:Individual
Prefix:DR
First Name:SHANE
Middle Name:EMBER
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:890 OAK ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-3905
Mailing Address - Country:US
Mailing Address - Phone:503-814-1278
Mailing Address - Fax:
Practice Address - Street 1:890 OAK ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3905
Practice Address - Country:US
Practice Address - Phone:503-814-1278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-31
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD171431207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine