Provider Demographics
NPI:1629317706
Name:BAZE, SHANE EMERSON (PT)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:EMERSON
Last Name:BAZE
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 1:16083 SW UPPER BOONES FERRY RD
Mailing Address - Street 2:SUITE 300
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 1:2728 PHEASANT BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-7509
Practice Address - Country:US
Practice Address - Phone:541-736-8870
Practice Address - Fax:541-736-8860
Is Sole Proprietor?:No
Enumeration Date:2013-02-08
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR60057225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500655109Medicaid
ORP01220789OtherRR MEDICARE
ORR168659Medicare PIN