Provider Demographics
NPI:1003482852
Name:ROGERS, SHANNON (PTA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:ROGERS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 WEAVER AVE
Mailing Address - Street 2:
Mailing Address - City:EMPORIA
Mailing Address - State:VA
Mailing Address - Zip Code:23847-1248
Mailing Address - Country:US
Mailing Address - Phone:434-336-5300
Mailing Address - Fax:434-336-5301
Practice Address - Street 1:219 WEAVER AVE
Practice Address - Street 2:
Practice Address - City:EMPORIA
Practice Address - State:VA
Practice Address - Zip Code:23847-1248
Practice Address - Country:US
Practice Address - Phone:434-336-5300
Practice Address - Fax:434-336-5301
Is Sole Proprietor?:No
Enumeration Date:2021-06-02
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306605719225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant