Provider Demographics
NPI:1811005416
Name:BAGLEY, SHAWN (PT)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:BAGLEY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 CENTRE PARK DR
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28805-1265
Mailing Address - Country:US
Mailing Address - Phone:828-505-2664
Mailing Address - Fax:
Practice Address - Street 1:226 CHARLOTTE HWY
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28803
Practice Address - Country:US
Practice Address - Phone:828-505-2664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4801225100000X
NC11242225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR134164Medicare ID - Type Unspecified