Provider Demographics
NPI:1144200676
Name:BAUER, SHANE D (PT)
Entity Type:Individual
Prefix:MR
First Name:SHANE
Middle Name:D
Last Name:BAUER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2105 E ENTERPRISE AVE STE 113
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-7862
Mailing Address - Country:US
Mailing Address - Phone:920-991-2561
Mailing Address - Fax:920-560-1147
Practice Address - Street 1:355 N PETERS AVE
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-8258
Practice Address - Country:US
Practice Address - Phone:920-929-9712
Practice Address - Fax:920-929-9715
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5173-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40340300Medicaid
WI000086596Medicare ID - Type UnspecifiedMEDICARE PROVIDER #