Basic Information
| Provider Information | |||||||||
| NPI: | 1467457564 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHELTON | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15214 CANYON RD E STE 120 | ||||||||
| Address2: | |||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983757472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535394200 | ||||||||
| FaxNumber: | 2535396005 | ||||||||
| Practice Location | |||||||||
| Address1: | 15214 CANYON RD E STE 120 | ||||||||
| Address2: | |||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983757472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535394200 | ||||||||
| FaxNumber: | 2535396005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2005 | ||||||||
| LastUpdateDate: | 04/06/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OP00001078 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0263650 | 01 | WA | STATE L&I | OTHER | 911465840 | 01 | WA | FEDERAL TAX ID | OTHER | 0267959 | 01 | WA | STATE L&I | OTHER | 0263658 | 01 | WA | STATE L&I | OTHER | 0263633 | 01 | WA | STATE L&I | OTHER | 0263655 | 01 | WA | STATE L&I | OTHER | 0263636 | 01 | WA | STATE L&I | OTHER | 0263630 | 01 | WA | STATE L&I | OTHER | 0263632 | 01 | WA | STATE L&I | OTHER | 0263638 | 01 | WA | STATE L&I | OTHER | 0255578 | 01 | WA | STATE L&I | OTHER | 0263641 | 01 | WA | STATE L&I | OTHER | 0263642 | 01 | WA | STATE L&I | OTHER | 0268165 | 01 | WA | STATE L&I | OTHER | 5840SH | 01 | WA | REGENCE BLUE SHIELD RIDER | OTHER |