Provider Demographics
NPI:1093728206
Name:HARTMAN, SHANE MICHAEL (MPT)
Entity Type:Individual
Prefix:MR
First Name:SHANE
Middle Name:MICHAEL
Last Name:HARTMAN
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 1:2297 KANSAS AVE SE STE 4
Mailing Address - Street 2:
Mailing Address - City:HURON
Mailing Address - State:SD
Mailing Address - Zip Code:57350-4274
Mailing Address - Country:US
Mailing Address - Phone:605-554-0388
Mailing Address - Fax:
Practice Address - Street 1:2297 KANSAS AVE SE STE 4
Practice Address - Street 2:
Practice Address - City:HURON
Practice Address - State:SD
Practice Address - Zip Code:57350-4274
Practice Address - Country:US
Practice Address - Phone:605-354-1546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1346225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5835852Medicaid
SD5835852Medicaid
6046760001Medicare NSC