Basic Information
| Provider Information | |||||||||
| NPI: | 1336119916 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SPEARS | ||||||||
| FirstName: | SHANE | ||||||||
| MiddleName: | FOREE | ||||||||
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| Credential: | PA-C, CCP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1802 YAKIMA AVE STE 102 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984055303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532727777 | ||||||||
| FaxNumber: | 3608745959 | ||||||||
| Practice Location | |||||||||
| Address1: | 1802 YAKIMA AVE STE 102 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984055303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532727777 | ||||||||
| FaxNumber: | 3608745959 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2006 | ||||||||
| LastUpdateDate: | 01/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA10004751 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | PA10004751 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1060261 | 05 | WA | MEDICAID | 9468232 | 01 | WA | AETNA | OTHER | 0225125 | 01 | WA | L&I AND CRIME VICTIMS | OTHER | 1425SP | 01 | WA | REGENCE | OTHER |