Provider Demographics
NPI:1760592208
Name:WEBER, SHAWN
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:WEBER
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:PSC 810 BOX 72
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09589-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PSC 810 BOX 72
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09589-0001
Practice Address - Country:US
Practice Address - Phone:314-960-9181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2006015453OtherLICENSE #