Provider Demographics
NPI:1124067087
Name:MARKEGARD, SHANNON LYNN (DO)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:LYNN
Last Name:MARKEGARD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:SHANNON
Other - Middle Name:LYNN
Other - Last Name:RYNEARSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3600 LIND AVE SW
Mailing Address - Street 2:STE 100
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-4934
Mailing Address - Country:US
Mailing Address - Phone:425-656-5412
Mailing Address - Fax:425-656-4079
Practice Address - Street 1:23846 SE KENT KANGLEY RD
Practice Address - Street 2:
Practice Address - City:MAPLE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:98038-6848
Practice Address - Country:US
Practice Address - Phone:425-656-4100
Practice Address - Fax:425-656-4109
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2008-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00002047207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8861630Medicare PIN
WAG8860706Medicare PIN
H34967Medicare UPIN
WAG8857604Medicare PIN