Healthcare Provider Details

I. General information

NPI: 1881883593
Provider Name (Legal Business Name): SHANNON ADAM BOUSTEAD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2007
Last Update Date: 08/15/2024
Certification Date: 08/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4455 CORDATA PKWY
BELLINGHAM WA
98226-8037
US

IV. Provider business mailing address

1401 MADISON ST
SEATTLE WA
98104-1316
US

V. Phone/Fax

Practice location:
  • Phone: 360-671-3225
  • Fax: 360-671-0000
Mailing address:
  • Phone: 206-541-4431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD60099520
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: