Provider Demographics
NPI:1639643372
Name:SHINE, ZACHARY (PTA)
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:
Last Name:SHINE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19395 W CAPITOL DR STE 200
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-2736
Mailing Address - Country:US
Mailing Address - Phone:262-923-7101
Mailing Address - Fax:262-923-7178
Practice Address - Street 1:19395 W CAPITOL DR STE 200
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-2736
Practice Address - Country:US
Practice Address - Phone:262-923-7101
Practice Address - Fax:262-923-7178
Is Sole Proprietor?:No
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2764225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant