Provider Demographics
NPI:1538709092
Name:SHADKO, WARREN (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:WARREN
Middle Name:
Last Name:SHADKO
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11335 NE 122ND WAY STE 105
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-6933
Mailing Address - Country:US
Mailing Address - Phone:425-298-7480
Mailing Address - Fax:
Practice Address - Street 1:11335 NE 122ND WAY STE 105
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-6933
Practice Address - Country:US
Practice Address - Phone:425-298-7480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-13
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC277126163WP0808X
NC5012834363LP0808X
NV836257363LP0808X
WAAP61098454363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health