Provider Demographics
NPI:1487178711
Name:SHONK, ANDREW
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:SHONK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 NE 102ND AVE # BLIDV
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-4169
Mailing Address - Country:US
Mailing Address - Phone:503-257-3327
Mailing Address - Fax:503-257-3374
Practice Address - Street 1:163 NE 102ND AVE BLID V
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220
Practice Address - Country:US
Practice Address - Phone:503-257-3327
Practice Address - Fax:503-257-3374
Is Sole Proprietor?:No
Enumeration Date:2017-07-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21837225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist