Healthcare Provider Details

I. General information

NPI: 1508760141
Provider Name (Legal Business Name): SHANE THOMAS BRANSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21810 NE 37TH AVE
RIDGEFIELD WA
98642-7747
US

IV. Provider business mailing address

12014 NW 19TH CT
VANCOUVER WA
98685-2475
US

V. Phone/Fax

Practice location:
  • Phone: 360-687-8555
  • Fax:
Mailing address:
  • Phone: 509-637-3746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: