Provider Demographics
NPI:1326249772
Name:HADLEY, SHANE M (AT)
Entity Type:Individual
Prefix:MR
First Name:SHANE
Middle Name:M
Last Name:HADLEY
Suffix:
Gender:M
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 BRISTOL ST N STE 25
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-8917
Mailing Address - Country:US
Mailing Address - Phone:949-250-1112
Mailing Address - Fax:949-250-1401
Practice Address - Street 1:1000 BRISTOL ST N STE 25
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-8917
Practice Address - Country:US
Practice Address - Phone:949-250-1112
Practice Address - Fax:949-250-1401
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT6305174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAT6305OtherPHYSICAL THERAPIST ASSIST