Provider Demographics
NPI:1477672897
Name:RUST, SHANNON M (PT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:RUST
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 1:290 DAYTON AVE APT 2E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-1887
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 RADIO DR
Practice Address - Street 2:STE 120
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-8409
Practice Address - Country:US
Practice Address - Phone:651-735-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2014-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5655225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist