Healthcare Provider Details

I. General information

NPI: 1952383432
Provider Name (Legal Business Name): SHANE SELASSIE ANDERSON MD PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2005
Last Update Date: 04/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 SW KLICKITAT WAY 205
SEATTLE WA
98134-1161
US

IV. Provider business mailing address

PO BOX 34245
SEATTLE WA
98124-1245
US

V. Phone/Fax

Practice location:
  • Phone: 206-622-7747
  • Fax: 206-467-1470
Mailing address:
  • Phone: 206-622-7747
  • Fax: 206-467-1470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License NumberMD00039332
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberMD00039332
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: