Provider Demographics
NPI:1699769786
Name:PATRICK, SHAWN TIMOTHY (MD)
Entity type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:TIMOTHY
Last Name:PATRICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 NW 22ND AVE
Mailing Address - Street 2:STE 660
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-3083
Mailing Address - Country:US
Mailing Address - Phone:503-413-7162
Mailing Address - Fax:
Practice Address - Street 1:2222 NW LOVEJOY ST
Practice Address - Street 2:SUITE 606
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3033
Practice Address - Country:US
Practice Address - Phone:503-229-7554
Practice Address - Fax:503-274-5400
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD22839174400000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1016616Medicaid
OR287717Medicaid
WA1016616Medicaid
OR287717Medicaid