Provider Demographics
NPI:1861032427
Name:VAN DECKER, SHAWN (PTA, OPTA, CPT)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:VAN DECKER
Suffix:
Gender:M
Credentials:PTA, OPTA, CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 WATKINS CENTRE PKWY
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23114-4404
Mailing Address - Country:US
Mailing Address - Phone:804-325-8822
Mailing Address - Fax:
Practice Address - Street 1:611 WATKINS CENTRE PKWY
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23114-4404
Practice Address - Country:US
Practice Address - Phone:804-325-8822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-13
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA23066035302081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine