Provider Demographics
NPI:1609856756
Name:GRIMES, SHAWN CHRISTOPHER (MSPT)
Entity Type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:CHRISTOPHER
Last Name:GRIMES
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16083 SW UPPER BOONES FERRY RD
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7736
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-639-9699
Practice Address - Street 1:283 NW MILLER AVE
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7260
Practice Address - Country:US
Practice Address - Phone:503-666-7644
Practice Address - Fax:503-674-9980
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8118225100000X
OR60017225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500699445Medicaid
CO990070610OtherRPN
ORR187371Medicare PIN
CO990070610OtherRPN
OR500699445Medicaid
ORR187369Medicare PIN
COC491328Medicare ID - Type Unspecified
ORR187373Medicare PIN
ORR187374Medicare PIN