Provider Demographics
NPI:1003004342
Name:TANAKA, SHINGO (MPT)
Entity Type:Individual
Prefix:MR
First Name:SHINGO
Middle Name:
Last Name:TANAKA
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 EAGLE CREST ST
Mailing Address - Street 2:
Mailing Address - City:RANGELY
Mailing Address - State:CO
Mailing Address - Zip Code:81648-3105
Mailing Address - Country:US
Mailing Address - Phone:970-675-4205
Mailing Address - Fax:970-675-4270
Practice Address - Street 1:225 EAGLE CREST ST
Practice Address - Street 2:
Practice Address - City:RANGELY
Practice Address - State:CO
Practice Address - Zip Code:81648-3105
Practice Address - Country:US
Practice Address - Phone:970-675-4205
Practice Address - Fax:970-675-4270
Is Sole Proprietor?:No
Enumeration Date:2007-10-11
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT011869225100000X
CO10367225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHTA4219771Medicare PIN
OHRI9365502Medicare PIN
OHRI9365501Medicare PIN
OHTA4219772Medicare PIN