Provider Demographics
NPI:1518741073
Name:O'BRENNAN, SHANE
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:O'BRENNAN
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 1:12750 CINNAMON CT
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-8703
Mailing Address - Country:US
Mailing Address - Phone:573-578-5702
Mailing Address - Fax:
Practice Address - Street 1:12750 CINNAMON CT
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-8703
Practice Address - Country:US
Practice Address - Phone:573-578-5702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-24
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist