Provider Demographics
NPI:1558478263
Name:SHANK, COBURN (MSPT)
Entity Type:Individual
Prefix:
First Name:COBURN
Middle Name:
Last Name:SHANK
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:COBY
Other - Middle Name:
Other - Last Name:SHANK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSPT
Mailing Address - Street 1:PO BOX 1475
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-1475
Mailing Address - Country:US
Mailing Address - Phone:515-222-7350
Mailing Address - Fax:515-222-7355
Practice Address - Street 1:1601 NW 114TH ST
Practice Address - Street 2:SUITE 155
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-7007
Practice Address - Country:US
Practice Address - Phone:515-222-7350
Practice Address - Fax:515-222-7355
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02418225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0452409Medicaid
IAQ30016Medicare UPIN
IAI14171Medicare ID - Type Unspecified