Provider Demographics
NPI:1629769914
Name:MATHEW, SHANE THOMAS (PT, DPT)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:THOMAS
Last Name:MATHEW
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9700 NW 48TH DR
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33076-2443
Mailing Address - Country:US
Mailing Address - Phone:954-675-9623
Mailing Address - Fax:
Practice Address - Street 1:40 DUKE MEDICINE CIR
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27710-6437
Practice Address - Country:US
Practice Address - Phone:919-684-2445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-17
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT40196225100000X
NCP22253225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist