Provider Demographics
NPI:1285824581
Name:EDYVEAN, SHAWN (PT)
Entity Type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:
Last Name:EDYVEAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 E CLOVERLAND DR
Mailing Address - Street 2:
Mailing Address - City:IRONWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49938-1606
Mailing Address - Country:US
Mailing Address - Phone:906-932-4200
Mailing Address - Fax:906-932-4201
Practice Address - Street 1:1310 E CLOVERLAND DR
Practice Address - Street 2:
Practice Address - City:IRONWOOD
Practice Address - State:MI
Practice Address - Zip Code:49938-1606
Practice Address - Country:US
Practice Address - Phone:906-932-4200
Practice Address - Fax:906-932-4201
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010780225100000X
WI9719-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40371700Medicaid