Provider Demographics
NPI:1568841625
Name:SHAN, KEZIAH
Entity Type:Individual
Prefix:
First Name:KEZIAH
Middle Name:
Last Name:SHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 CENTER DR APT 112
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:TX
Mailing Address - Zip Code:76384-4833
Mailing Address - Country:US
Mailing Address - Phone:940-261-0677
Mailing Address - Fax:
Practice Address - Street 1:2100 CENTER DR APT 112
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:TX
Practice Address - Zip Code:76384-4833
Practice Address - Country:US
Practice Address - Phone:940-261-0677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-22
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT42354225100000X
TX1225098225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist