Provider Demographics
NPI:1598732620
Name:SHAN, JING (PT)
Entity Type:Individual
Prefix:
First Name:JING
Middle Name:
Last Name:SHAN
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 1:2415 BELL BLVD
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11360-2222
Mailing Address - Country:US
Mailing Address - Phone:718-357-3638
Mailing Address - Fax:
Practice Address - Street 1:2415 BELL BLVD
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11360-2222
Practice Address - Country:US
Practice Address - Phone:718-357-3638
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0183202251P0200X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Not Answered2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02459814Medicaid
NY05919Medicare ID - Type Unspecified