Provider Demographics
NPI:1508946005
Name:MOORE, SHAWN A (MPT, CSCS)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:A
Last Name:MOORE
Suffix:
Gender:M
Credentials:MPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 KITDARE DR
Mailing Address - Street 2:
Mailing Address - City:DELAWARE
Mailing Address - State:OH
Mailing Address - Zip Code:43015-7077
Mailing Address - Country:US
Mailing Address - Phone:419-656-7084
Mailing Address - Fax:
Practice Address - Street 1:1069 DELAWARE AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-6464
Practice Address - Country:US
Practice Address - Phone:740-382-1734
Practice Address - Fax:740-387-6918
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT08805225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2429438Medicaid
OH4064461Medicare PIN