Provider Demographics
NPI:1982993770
Name:STACK, SHOBHA WILLIAMSON (MD)
Entity Type:Individual
Prefix:DR
First Name:SHOBHA
Middle Name:WILLIAMSON
Last Name:STACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHOBHA
Other - Middle Name:DEVI
Other - Last Name:WILLIAMSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12040 NE 128TH ST
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-3013
Mailing Address - Country:US
Mailing Address - Phone:425-542-3630
Mailing Address - Fax:
Practice Address - Street 1:12040 NE 128TH ST
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-3013
Practice Address - Country:US
Practice Address - Phone:425-542-3630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-01
Last Update Date:2022-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60503747207R00000X
WA60503747207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8936088OtherMEDICARE PIN
WA1982993770Medicaid
WA8936088Medicare PIN