Provider Demographics
NPI:1821468646
Name:SHAW, CORISSA DAWN (PTA)
Entity Type:Individual
Prefix:
First Name:CORISSA
Middle Name:DAWN
Last Name:SHAW
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:CORISSA
Other - Middle Name:DAWN
Other - Last Name:TREJO, LAHMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:414 E 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:HUTCHINSON
Mailing Address - State:KS
Mailing Address - Zip Code:67501-1426
Mailing Address - Country:US
Mailing Address - Phone:620-663-5932
Mailing Address - Fax:
Practice Address - Street 1:414 E 8TH AVE
Practice Address - Street 2:
Practice Address - City:HUTCHINSON
Practice Address - State:KS
Practice Address - Zip Code:67501-1426
Practice Address - Country:US
Practice Address - Phone:620-663-5932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-06
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1402891225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant