Provider Demographics
NPI:1417469362
Name:SHAMBLIN, TYLER (DPT)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:SHAMBLIN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 ROSEMAR RD STE 1
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26104-7609
Mailing Address - Country:US
Mailing Address - Phone:304-693-2781
Mailing Address - Fax:304-693-2171
Practice Address - Street 1:313 MACCORKLE AVE SW
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25303-1263
Practice Address - Country:US
Practice Address - Phone:304-746-3704
Practice Address - Fax:304-744-5891
Is Sole Proprietor?:No
Enumeration Date:2017-11-01
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV003877225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist