Provider Demographics
NPI:1821237652
Name:WILLIS BAKER, SHAYNE NICOLE (PT, DPT, ATC, CIMT)
Entity Type:Individual
Prefix:
First Name:SHAYNE
Middle Name:NICOLE
Last Name:WILLIS BAKER
Suffix:
Gender:F
Credentials:PT, DPT, ATC, CIMT
Other - Prefix:
Other - First Name:SHAYNE
Other - Middle Name:NICOLE
Other - Last Name:WILLIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT, DPT, ATC, CIMT
Mailing Address - Street 1:3303 S BOND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-4501
Mailing Address - Country:US
Mailing Address - Phone:503-494-3151
Mailing Address - Fax:
Practice Address - Street 1:3303 S BOND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4501
Practice Address - Country:US
Practice Address - Phone:503-494-3151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-18
Last Update Date:2020-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5021208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation