Provider Demographics
NPI:1225486582
Name:RAGAZA, SHELESH
Entity Type:Individual
Prefix:
First Name:SHELESH
Middle Name:
Last Name:RAGAZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3550 ROUND BARN BLVD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-1796
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:815 N INDEPENDENCE AVE
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:KS
Practice Address - Zip Code:67420-1639
Practice Address - Country:US
Practice Address - Phone:785-577-0658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-27
Last Update Date:2021-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-04972225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS11-04972OtherKS STATE BOARD OF HEALING ARTS PT LICENSE