Provider Demographics
NPI:1922158377
Name:AXTEN, SHAWN D (PT,CST-D)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:D
Last Name:AXTEN
Suffix:
Gender:F
Credentials:PT,CST-D
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 444
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97709-0444
Mailing Address - Country:US
Mailing Address - Phone:541-600-4651
Mailing Address - Fax:541-600-4731
Practice Address - Street 1:2955 N HWY 97
Practice Address - Street 2:100
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-7559
Practice Address - Country:US
Practice Address - Phone:541-600-4651
Practice Address - Fax:541-600-4731
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2017-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAWAPT00005742081P0010X
OR01557261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No2081P0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPediatric Rehabilitation Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR01557OtherOREGON PT LICENSING BOARD
WA00005748OtherWA PHYSICAL THERAPY LICENSING BOARD