Healthcare Provider Details

I. General information

NPI: 1861055006
Provider Name (Legal Business Name): SHAD FLY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2019
Last Update Date: 06/22/2022
Certification Date: 06/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 W 5TH AVE
SPOKANE WA
99204-2803
US

IV. Provider business mailing address

23225 E MAXWELL AVE
LIBERTY LAKE WA
99019-8559
US

V. Phone/Fax

Practice location:
  • Phone: 509-458-5800
  • Fax:
Mailing address:
  • Phone: 661-231-5443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP61299457
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: