Provider Demographics
NPI:1750850095
Name:WILSON, SHAWNA SUE (PTA)
Entity Type:Individual
Prefix:
First Name:SHAWNA
Middle Name:SUE
Last Name:WILSON
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 1:2409 DEBORAH DR SW
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52404-3714
Mailing Address - Country:US
Mailing Address - Phone:319-470-3751
Mailing Address - Fax:
Practice Address - Street 1:502 N 9TH AVE
Practice Address - Street 2:
Practice Address - City:VINTON
Practice Address - State:IA
Practice Address - Zip Code:52349-2254
Practice Address - Country:US
Practice Address - Phone:319-472-6220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-15
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA092206208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation