Provider Demographics
NPI:1861930539
Name:BIBB, SHAWN
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:BIBB
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 16756
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97292-0756
Mailing Address - Country:US
Mailing Address - Phone:971-386-3401
Mailing Address - Fax:503-208-2596
Practice Address - Street 1:704 MAIN ST STE 302
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-1842
Practice Address - Country:US
Practice Address - Phone:971-386-3401
Practice Address - Fax:503-723-6653
Is Sole Proprietor?:No
Enumeration Date:2017-02-02
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16-CRM-005175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist