Provider Demographics
NPI:1861458077
Name:GOSS, SHANE E (PT)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:E
Last Name:GOSS
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:PO BOX 218
Mailing Address - Street 2:
Mailing Address - City:MORENCI
Mailing Address - State:AZ
Mailing Address - Zip Code:85540-0218
Mailing Address - Country:US
Mailing Address - Phone:928-865-7567
Mailing Address - Fax:928-865-9186
Practice Address - Street 1:401 BURRO ALY
Practice Address - Street 2:
Practice Address - City:MORENCI
Practice Address - State:AZ
Practice Address - Zip Code:85540-9647
Practice Address - Country:US
Practice Address - Phone:928-865-7567
Practice Address - Fax:928-865-9186
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7043225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZQ57000Medicare UPIN