Healthcare Provider Details

I. General information

NPI: 1487188652
Provider Name (Legal Business Name): SHANE BRENT GOLLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2017
Last Update Date: 10/25/2023
Certification Date: 10/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040 JACKSON AVE
TACOMA WA
98431-1100
US

IV. Provider business mailing address

9040 REID ST
JOINT BASE LEWIS MCCHORD WA
98431-1101
US

V. Phone/Fax

Practice location:
  • Phone: 253-477-0838
  • Fax:
Mailing address:
  • Phone: 253-968-1110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0101265466
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0101265466
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: