Basic Information
| Provider Information | |||||||||
| NPI: | 1710151238 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GATES | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | D. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1344 WINTERGREEN LN NE UNIT 100 | ||||||||
| Address2: | |||||||||
| City: | BAINBRIDGE ISLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981105147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062010488 | ||||||||
| FaxNumber: | 2062010490 | ||||||||
| Practice Location | |||||||||
| Address1: | 1344 WINTERGREEN LN NE STE 100 | ||||||||
| Address2: | |||||||||
| City: | BAINBRIDGE ISLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981105118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062010488 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2008 | ||||||||
| LastUpdateDate: | 10/13/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | A103930 | CA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | MD60612568 | WA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2130389 | 05 | WA | MEDICAID |