Provider Demographics
NPI:1407031750
Name:IWAE, SHIRO (PT)
Entity Type:Individual
Prefix:MR
First Name:SHIRO
Middle Name:
Last Name:IWAE
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 1:1653 LINKSIDE CT N
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32233
Mailing Address - Country:US
Mailing Address - Phone:904-241-9500
Mailing Address - Fax:904-241-2009
Practice Address - Street 1:1401 PENMAN RD
Practice Address - Street 2:SUITE C
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250
Practice Address - Country:US
Practice Address - Phone:904-241-9500
Practice Address - Fax:904-241-2009
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-07
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT10623225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist