Provider Demographics
NPI:1578641700
Name:SHIN, SANGYONG (PT)
Entity Type:Individual
Prefix:
First Name:SANGYONG
Middle Name:
Last Name:SHIN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14001 E ILIFF AVE STE 215
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80014-1426
Mailing Address - Country:US
Mailing Address - Phone:303-341-2277
Mailing Address - Fax:303-341-7722
Practice Address - Street 1:14001 E ILIFF AVE STE 215
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-1426
Practice Address - Country:US
Practice Address - Phone:303-341-2277
Practice Address - Fax:303-341-7722
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO79502251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO67782566Medicaid
CO67782566Medicaid