Provider Demographics
NPI:1861466484
Name:SHIELDS, NATHAN R (PT)
Entity Type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:R
Last Name:SHIELDS
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 873895
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99687-3895
Mailing Address - Country:US
Mailing Address - Phone:480-695-3343
Mailing Address - Fax:
Practice Address - Street 1:3066 E MERIDIAN PARK LOOP STE 101
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654
Practice Address - Country:US
Practice Address - Phone:907-205-5945
Practice Address - Fax:907-205-5948
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5063225100000X
AK1093062251E1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251E1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistElectrophysiology, Clinical
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1651715Medicaid