Provider Demographics
NPI:1558715433
Name:BLOSS, SHAWN
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:BLOSS
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 1:16 TIMBERLINE DR
Mailing Address - Street 2:
Mailing Address - City:ESKO
Mailing Address - State:MN
Mailing Address - Zip Code:55733-9500
Mailing Address - Country:US
Mailing Address - Phone:218-260-9043
Mailing Address - Fax:
Practice Address - Street 1:16 TIMBERLINE DR
Practice Address - Street 2:
Practice Address - City:ESKO
Practice Address - State:MN
Practice Address - Zip Code:55733-9500
Practice Address - Country:US
Practice Address - Phone:218-260-9043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-18
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN104634225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation