Healthcare Provider Details

I. General information

NPI: 1255533428
Provider Name (Legal Business Name): SHANE JAY TOSIHIRO RUTER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2007
Last Update Date: 06/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 9TH AVE
SEATTLE WA
98104-2499
US

IV. Provider business mailing address

PO BOX 359702 325 9TH AVE
SEATTLE WA
98104-2499
US

V. Phone/Fax

Practice location:
  • Phone: 206-744-3074
  • Fax: 206-744-8546
Mailing address:
  • Phone: 206-744-3074
  • Fax: 206-744-8546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD60206164
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: