Healthcare Provider Details

I. General information

NPI: 1154374965
Provider Name (Legal Business Name): DAVID B SHANLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 05/14/2021
Certification Date: 04/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 NW 11TH ST STE M103
HERMISTON OR
97838-6941
US

IV. Provider business mailing address

620 NW 11TH ST STE M201
HERMISTON OR
97838-6941
US

V. Phone/Fax

Practice location:
  • Phone: 541-667-3830
  • Fax:
Mailing address:
  • Phone: 541-289-4118
  • Fax: 541-667-3484

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2009-0628
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD60746432
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD199547
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: