Provider Demographics
NPI:1932338506
Name:HERMES SHANTZ, HEIDI M (MD)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:M
Last Name:HERMES SHANTZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:M
Other - Last Name:HERMES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:565 EUREKA WAY
Mailing Address - Street 2:
Mailing Address - City:SEQUIM
Mailing Address - State:WA
Mailing Address - Zip Code:98382-5074
Mailing Address - Country:US
Mailing Address - Phone:360-582-0808
Mailing Address - Fax:253-984-2049
Practice Address - Street 1:565 EUREKA WAY
Practice Address - Street 2:
Practice Address - City:SEQUIM
Practice Address - State:WA
Practice Address - Zip Code:98382-5074
Practice Address - Country:US
Practice Address - Phone:360-582-0808
Practice Address - Fax:253-984-2049
Is Sole Proprietor?:No
Enumeration Date:2009-07-04
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD.6047903207N00000X, 207NS0135X, 207ND0101X
WAMD60479603207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2038330Medicaid