MEDICARE: MARY ELLEN SHIELDS M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	MD00017067	WA

General Provider Information

NPI Number	:	1932257144
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY ELLEN SHIELDS M.D.

Provider Business Mailing Address
First Line	:	6760 MISSION RD
Second Line	:
City	:	EVERSON
State	:	WA
Zip	:	98247-9749
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6760 MISSION RD
Second Line	:
City	:	EVERSON
State	:	WA
Zip	:	98247-9749
Country	:	US
Telephone Number	:	360-966-2106
Fax Number	:	360-966-2304

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/08/2007
Last Update Date	:	03/31/2021

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