Provider Demographics
NPI:1003309667
Name:ROBERTSON, SHAWN (LAC)
Entity Type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 SW HIGGINS AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59803-1340
Mailing Address - Country:US
Mailing Address - Phone:406-540-0081
Mailing Address - Fax:406-284-0678
Practice Address - Street 1:1001 SW HIGGINS AVE STE 104
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59803-1340
Practice Address - Country:US
Practice Address - Phone:406-540-0081
Practice Address - Fax:406-284-0678
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-08
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-ACU-LIC-67145171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist