Provider Demographics
NPI:1659138204
Name:SHANE, PAIGE ROCHELLE (PTA)
Entity Type:Individual
Prefix:
First Name:PAIGE
Middle Name:ROCHELLE
Last Name:SHANE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1762 S BUCHANAN ST
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43420-4943
Mailing Address - Country:US
Mailing Address - Phone:419-701-1355
Mailing Address - Fax:
Practice Address - Street 1:1762 S BUCHANAN ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-4943
Practice Address - Country:US
Practice Address - Phone:419-701-1355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-29
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA013087208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation