Provider Demographics
NPI:1376979591
Name:SHARK, THERESA ANN (PT)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:ANN
Last Name:SHARK
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 1:476 OTIS DR
Mailing Address - Street 2:
Mailing Address - City:RIPON
Mailing Address - State:CA
Mailing Address - Zip Code:95366-3337
Mailing Address - Country:US
Mailing Address - Phone:505-274-0884
Mailing Address - Fax:
Practice Address - Street 1:103 E MAIN ST
Practice Address - Street 2:
Practice Address - City:RIPON
Practice Address - State:CA
Practice Address - Zip Code:95366-2416
Practice Address - Country:US
Practice Address - Phone:209-599-7073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-19
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28975225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist