Provider Demographics
NPI:1598986002
Name:EVERSON, SHAWN K (MHS, PT, OCS, MTC)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:K
Last Name:EVERSON
Suffix:
Gender:M
Credentials:MHS, PT, OCS, MTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:763 S NEW BALLAS RD
Mailing Address - Street 2:200
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8704
Mailing Address - Country:US
Mailing Address - Phone:314-991-2562
Mailing Address - Fax:
Practice Address - Street 1:763 S NEW BALLAS RD
Practice Address - Street 2:200
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8704
Practice Address - Country:US
Practice Address - Phone:314-991-2562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01532225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
25456Medicare PIN