Provider Demographics
NPI:1497531958
Name:SHINE, MATTHEW MORGAN
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:MORGAN
Last Name:SHINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 309
Mailing Address - Street 2:
Mailing Address - City:LA PLACE
Mailing Address - State:LA
Mailing Address - Zip Code:70069-0309
Mailing Address - Country:US
Mailing Address - Phone:504-525-2225
Mailing Address - Fax:504-324-8276
Practice Address - Street 1:4637 S CARROLLTON AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-6024
Practice Address - Country:US
Practice Address - Phone:504-525-2225
Practice Address - Fax:504-324-8276
Is Sole Proprietor?:No
Enumeration Date:2023-08-31
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA103062251E1200X, 2251G0304X, 2251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251E1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistErgonomics
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic