Healthcare Provider Details

I. General information

NPI: 1548502446
Provider Name (Legal Business Name): WHITNEY LEIGH SHOFNER MICHALSKY M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2013
Last Update Date: 11/25/2020
Certification Date: 11/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 E BANNOCK ST
BOISE ID
83712-6241
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 206-386-2123
  • Fax: 206-386-6293
Mailing address:
  • Phone: 206-386-2123
  • Fax: 206-386-6293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberM-14673
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number60585504
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMDRE.ML.60375715
License Number StateWA
# 4
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberM14673
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: