=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205341401
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK SHORTT ND
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/10/2017
-----------------------------------------------------
Last Update Date | 12/10/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2115 1/2 2ND AVE W
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98119-2604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-504-8190
-----------------------------------------------------
Fax | 206-504-8190
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3514 BURKE AVE N
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98103-9028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-504-8190
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 175F00000X
-----------------------------------------------------
Taxonomy Name | Naturopath
-----------------------------------------------------
License Number | NT60796371
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------