Provider Demographics
NPI:1457323396
Name:WALLACE, SHAWN G (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:G
Last Name:WALLACE
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13390 NE 23RD ST
Mailing Address - Street 2:
Mailing Address - City:CHOCTAW
Mailing Address - State:OK
Mailing Address - Zip Code:73020-8622
Mailing Address - Country:US
Mailing Address - Phone:405-769-5555
Mailing Address - Fax:405-769-5558
Practice Address - Street 1:13390 NE 23RD ST
Practice Address - Street 2:
Practice Address - City:CHOCTAW
Practice Address - State:OK
Practice Address - Zip Code:73020-8622
Practice Address - Country:US
Practice Address - Phone:405-769-5555
Practice Address - Fax:405-769-5558
Is Sole Proprietor?:No
Enumeration Date:2006-02-05
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPT1769225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist