Basic Information
Provider Information
NPI: 1003009283
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SOLBERG-SHANKLE
FirstName: HEIDI
MiddleName: MARIE
NamePrefix: DR.
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1615 DELAWARE ST
Address2: PO BOX 3002
City: LONGVIEW
State: WA
PostalCode: 986322367
CountryCode: US
TelephoneNumber: 3606364116
FaxNumber: 3606364955
Practice Location
Address1: 1615 DELAWARE ST
Address2: ST. JOHN EMERGENCY DEPARTMENT
City: LONGVIEW
State: WA
PostalCode: 986322367
CountryCode: US
TelephoneNumber: 3606364116
FaxNumber: 3606364955
Other Information
ProviderEnumerationDate: 08/22/2007
LastUpdateDate: 04/06/2011
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207P00000XMD 60073277WAY Allopathic & Osteopathic PhysiciansEmergency Medicine 
390200000X  N Student, Health CareStudent in an Organized Health Care Education/Training Program 

ID Information
IDTypeStateIssuerDescription
854319105WA MEDICAID


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