Provider Demographics
NPI:1831461250
Name:LAZCANO, SHANNON (PTA)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:
Last Name:LAZCANO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MISS
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:ROPEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:641 S 67TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53214-1747
Mailing Address - Country:US
Mailing Address - Phone:414-322-5564
Mailing Address - Fax:
Practice Address - Street 1:7517 W COLDSPRING RD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53220-2814
Practice Address - Country:US
Practice Address - Phone:414-327-6603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-31
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI954-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant