Basic Information
| Provider Information | |||||||||
| NPI: | 1265473037 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANTOS | ||||||||
| FirstName: | SHARON | ||||||||
| MiddleName: | RH | ||||||||
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| Credential: | MD | ||||||||
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| OtherLastName: | HORMACHUELOS-SANTOS | ||||||||
| OtherFirstName: | SHARON | ||||||||
| OtherMiddleName: | ROSE | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1706 S MERIDIAN | ||||||||
| Address2: | STE 120 | ||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538488797 | ||||||||
| FaxNumber: | 2534463239 | ||||||||
| Practice Location | |||||||||
| Address1: | 10004 204TH AVE E | ||||||||
| Address2: | SUITE 1300 | ||||||||
| City: | BONNEY LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983916535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538488797 | ||||||||
| FaxNumber: | 2538261264 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 11/14/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD00040355 | WA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 8286262 | 05 | WA | MEDICAID |