=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326236498
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANE HAUPT L.M.P.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2007
-----------------------------------------------------
Last Update Date | 10/13/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11701 NE 95TH ST STE C
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98682-2318
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-513-2654
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3021 NE 72ND DR STE 9-63
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98661-7300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-513-2654
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | MA00020575
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------