Provider Demographics
NPI:1528632825
Name:SHUPE, IAN THOMAS (MSPAS, PA-C, RT(R))
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:THOMAS
Last Name:SHUPE
Suffix:
Gender:M
Credentials:MSPAS, PA-C, RT(R)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17607 SW FALLING LEAF CT
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97003-7558
Mailing Address - Country:US
Mailing Address - Phone:360-991-2491
Mailing Address - Fax:
Practice Address - Street 1:842 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7155
Practice Address - Country:US
Practice Address - Phone:541-618-5800
Practice Address - Fax:541-779-3027
Is Sole Proprietor?:No
Enumeration Date:2021-05-19
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA.PA.61159625363A00000X
ORPA204375363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant