Provider Demographics
NPI:1669662326
Name:SHAVER, SETH T (PTA)
Entity Type:Individual
Prefix:MR
First Name:SETH
Middle Name:T
Last Name:SHAVER
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 1:2911 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-1105
Mailing Address - Country:US
Mailing Address - Phone:719-251-4411
Mailing Address - Fax:719-275-0442
Practice Address - Street 1:903 MOORE DR
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:CO
Practice Address - Zip Code:81226-9509
Practice Address - Country:US
Practice Address - Phone:719-251-4411
Practice Address - Fax:719-275-0442
Is Sole Proprietor?:No
Enumeration Date:2007-07-30
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPTA-456225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYPTA-456OtherPTA LICENSURE