Provider Demographics
NPI:1215036751
Name:SKIDMORE, SHARON B (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:SHARON
Middle Name:B
Last Name:SKIDMORE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1475
Mailing Address - Street 2:
Mailing Address - City:SISTERS
Mailing Address - State:OR
Mailing Address - Zip Code:97759-1475
Mailing Address - Country:US
Mailing Address - Phone:907-346-4096
Mailing Address - Fax:877-319-7365
Practice Address - Street 1:1109 N FOREST EDGE DR
Practice Address - Street 2:
Practice Address - City:SISTERS
Practice Address - State:OR
Practice Address - Zip Code:97759-2692
Practice Address - Country:US
Practice Address - Phone:907-346-4096
Practice Address - Fax:877-319-7365
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK783225100000X, 2251P0200X
MA10338225100000X
COPTL.0003243225100000X, 2251P0200X
OR26232251P0200X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR2623OtherOR BOARD OF PHYSICAL THERAPY
AK1029669Medicaid
AK783OtherALASKA BOARD OF PT AND OT
COPTL.0003243OtherCO DEPARTMENT OF REGULARTORY AGENCIES
OR500783631Medicaid