Provider Demographics
NPI:1265524912
Name:SHIDELER, BLYNN L (MD, PC)
Entity type:Individual
Prefix:
First Name:BLYNN
Middle Name:L
Last Name:SHIDELER
Suffix:
Gender:M
Credentials:MD, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 NW GILMAN BLVD
Mailing Address - Street 2:SUITE 2-2786
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-5394
Mailing Address - Country:US
Mailing Address - Phone:425-996-1001
Mailing Address - Fax:206-600-5033
Practice Address - Street 1:576 HARTNELL ST
Practice Address - Street 2:SUITE 200
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940-2833
Practice Address - Country:US
Practice Address - Phone:425-996-1001
Practice Address - Fax:206-600-5033
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG23099208600000X
WAMD00045810208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG23099Medicare ID - Type UnspecifiedMD