Provider Demographics
NPI:1235434721
Name:REGNER, SHANNON L (PT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:REGNER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:357 BAY RD 4
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-3051
Mailing Address - Country:US
Mailing Address - Phone:518-632-4944
Mailing Address - Fax:518-632-4945
Practice Address - Street 1:357 BAY RD 4
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-3051
Practice Address - Country:US
Practice Address - Phone:518-632-4944
Practice Address - Fax:518-632-4945
Is Sole Proprietor?:No
Enumeration Date:2011-01-14
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025436-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist