Provider Demographics
NPI:1205216124
Name:HOGUE, SHANNON MARIKO (PT, MPT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIKO
Last Name:HOGUE
Suffix:
Gender:F
Credentials:PT, MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2518 MISSION COLLEGE BLVD
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95054-1239
Mailing Address - Country:US
Mailing Address - Phone:408-688-9720
Mailing Address - Fax:
Practice Address - Street 1:2518 MISSION COLLEGE BLVD
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95054-1239
Practice Address - Country:US
Practice Address - Phone:408-688-9775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-05
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42411225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist