Provider Demographics
NPI:1003442898
Name:WALDBAUM, SHAYNA ROSE
Entity type:Individual
Prefix:
First Name:SHAYNA
Middle Name:ROSE
Last Name:WALDBAUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 SW ALASKA ST STE B
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98116-4527
Mailing Address - Country:US
Mailing Address - Phone:206-320-3399
Mailing Address - Fax:
Practice Address - Street 1:4100 SW ALASKA ST STE B
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98116-4527
Practice Address - Country:US
Practice Address - Phone:206-320-3399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-12
Last Update Date:2025-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPG222196207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine