Basic Information
| Provider Information | |||||||||
| NPI: | 1760588099 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHIVELEY | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | JAMES | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1313 BROADWAY PLAZA | ||||||||
| Address2: | STE 200 | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984023400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2534266306 | ||||||||
| FaxNumber: | 2534266344 | ||||||||
| Practice Location | |||||||||
| Address1: | 1313 BROADWAY PLAZA | ||||||||
| Address2: | STE 200 | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984023400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2534266306 | ||||||||
| FaxNumber: | 2534266344 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2006 | ||||||||
| LastUpdateDate: | 06/29/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | MD00046533 | WA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 0242294 | 01 | WA | STATE L&I | OTHER |