Provider Demographics
NPI:1316915309
Name:WALTER, SHANE A (IDC)
Entity type:Individual
Prefix:MR
First Name:SHANE
Middle Name:A
Last Name:WALTER
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 NE SHOREWOOD CT
Mailing Address - Street 2:
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-8436
Mailing Address - Country:US
Mailing Address - Phone:360-598-5312
Mailing Address - Fax:
Practice Address - Street 1:BHC BANGOR, 2050 BARB ST
Practice Address - Street 2:SUITE A, NAVAL SUBMARINE BASE BANGOR
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98315-2099
Practice Address - Country:US
Practice Address - Phone:360-315-4356
Practice Address - Fax:360-396-4247
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA0I1002X1711710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman