Provider Demographics
NPI:1598408817
Name:VAN WAITE, SHELBY MAE (MD)
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:MAE
Last Name:VAN WAITE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3550 N INTERSTATE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1196
Mailing Address - Country:US
Mailing Address - Phone:800-813-2000
Mailing Address - Fax:
Practice Address - Street 1:10100 SE SUNNYSIDE RD
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-8970
Practice Address - Country:US
Practice Address - Phone:800-813-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-14
Last Update Date:2025-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61684463207Q00000X
ORMD225310207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty