Provider Demographics
NPI:1922038439
Name:SHAULL, KEITH ALAN (PT)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:ALAN
Last Name:SHAULL
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 1:11421 E PALOMA AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85212-1971
Mailing Address - Country:US
Mailing Address - Phone:480-813-0349
Mailing Address - Fax:
Practice Address - Street 1:5440 E SOUTHERN AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-2779
Practice Address - Country:US
Practice Address - Phone:480-641-3533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7213225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist