Provider Demographics
NPI:1114009479
Name:BASOM, SHANA MARLENE (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:MS
First Name:SHANA
Middle Name:MARLENE
Last Name:BASOM
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:735 SW 158TH AVE
Mailing Address - Street 2:STE 160
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-4952
Mailing Address - Country:US
Mailing Address - Phone:503-597-0035
Mailing Address - Fax:503-296-2985
Practice Address - Street 1:735 SW 158TH AVE
Practice Address - Street 2:STE 160
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-4952
Practice Address - Country:US
Practice Address - Phone:503-597-0035
Practice Address - Fax:503-296-2985
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5283225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP00393828OtherRAILROAD MEDICARE
ORR135896Medicare PIN
ORP00393828OtherRAILROAD MEDICARE