Provider Demographics
NPI:1255826608
Name:SHILLINGBURG, DWAYNE (PTA)
Entity Type:Individual
Prefix:
First Name:DWAYNE
Middle Name:
Last Name:SHILLINGBURG
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 MYLAN PARK LN
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26501-2281
Mailing Address - Country:US
Mailing Address - Phone:304-983-7766
Mailing Address - Fax:304-983-7768
Practice Address - Street 1:460 MYLAN PARK LN
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26501-2281
Practice Address - Country:US
Practice Address - Phone:304-983-7766
Practice Address - Fax:304-983-7768
Is Sole Proprietor?:No
Enumeration Date:2018-06-28
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant