Provider Demographics
NPI:1679922884
Name:PIATT, SHANE
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:PIATT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 LOCUST AVE STE A
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-1293
Mailing Address - Country:US
Mailing Address - Phone:304-333-5222
Mailing Address - Fax:304-333-5224
Practice Address - Street 1:1900 LOCUST AVE STE A
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554
Practice Address - Country:US
Practice Address - Phone:304-333-5222
Practice Address - Fax:304-333-5224
Is Sole Proprietor?:No
Enumeration Date:2016-06-08
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3631225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist