Provider Demographics
NPI:1306542840
Name:MIRE, SHAWN ANTHONY
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:ANTHONY
Last Name:MIRE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:SHAWN
Other - Middle Name:ANTHONY
Other - Last Name:ORNDORFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2278 QUINNS MEADOW RD LOT B
Mailing Address - Street 2:
Mailing Address - City:COLVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:99114-5145
Mailing Address - Country:US
Mailing Address - Phone:206-590-0255
Mailing Address - Fax:
Practice Address - Street 1:909 W MAIN ST STE 102
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-2031
Practice Address - Country:US
Practice Address - Phone:360-453-7715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist