Provider Demographics
NPI:1003066853
Name:PEDERSON, SHANE MARLON (PT)
Entity Type:Individual
Prefix:MR
First Name:SHANE
Middle Name:MARLON
Last Name:PEDERSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:123 WEST MILE 3 ROAD
Mailing Address - Street 2:SUITE A-103
Mailing Address - City:PALMHURST
Mailing Address - State:TX
Mailing Address - Zip Code:78573
Mailing Address - Country:US
Mailing Address - Phone:956-585-9889
Mailing Address - Fax:956-585-9896
Practice Address - Street 1:123 WEST MILE 3 ROAD
Practice Address - Street 2:SUITE A-103
Practice Address - City:PALMHURST
Practice Address - State:TX
Practice Address - Zip Code:78573
Practice Address - Country:US
Practice Address - Phone:956-585-9889
Practice Address - Fax:956-585-9896
Is Sole Proprietor?:No
Enumeration Date:2008-09-29
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1155757225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist