Provider Demographics
NPI:1396200317
Name:CAPONE, SHAYNE MATTHEW (PTA)
Entity Type:Individual
Prefix:
First Name:SHAYNE
Middle Name:MATTHEW
Last Name:CAPONE
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 1:1568 LAKE LANSING RD STE B
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48912-3707
Mailing Address - Country:US
Mailing Address - Phone:517-483-2734
Mailing Address - Fax:
Practice Address - Street 1:1568 LAKE LANSING RD STE B
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-3707
Practice Address - Country:US
Practice Address - Phone:517-483-2734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-04
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502005446225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5502005446Medicaid