Provider Demographics
NPI:1992897276
Name:RADKE, SHANNON B (MD)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:B
Last Name:RADKE
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 W PINE ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:WA
Mailing Address - Zip Code:99156-9046
Mailing Address - Country:US
Mailing Address - Phone:509-447-2441
Mailing Address - Fax:509-447-0456
Practice Address - Street 1:714 W PINE ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:WA
Practice Address - Zip Code:99156-9046
Practice Address - Country:US
Practice Address - Phone:509-447-2441
Practice Address - Fax:509-447-0456
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00036530207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806529300Medicaid
WA8345274Medicaid
WA8345274Medicaid