Provider Demographics
NPI:1710695127
Name:FENG, SHUO
Entity Type:Individual
Prefix:
First Name:SHUO
Middle Name:
Last Name:FENG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 GREENBRIAR CIR UNIT 700A
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-4004
Mailing Address - Country:US
Mailing Address - Phone:316-322-5228
Mailing Address - Fax:
Practice Address - Street 1:700 GREENBRIAR CIR UNIT 700A
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-4004
Practice Address - Country:US
Practice Address - Phone:316-322-5228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT300281225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist