Provider Demographics
NPI:1033613161
Name:SHANNON, GAVIN (PTA)
Entity Type:Individual
Prefix:
First Name:GAVIN
Middle Name:
Last Name:SHANNON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:OH
Mailing Address - Zip Code:43080-7704
Mailing Address - Country:US
Mailing Address - Phone:740-641-7761
Mailing Address - Fax:
Practice Address - Street 1:339 E MAPLE ST
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-2593
Practice Address - Country:US
Practice Address - Phone:330-498-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-22
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA011265225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant