Provider Demographics
NPI:1922313402
Name:WHERRY, SHAWN T (PTA)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:T
Last Name:WHERRY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2651 IRVINE AVE
Mailing Address - Street 2:SUITE 128
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-4628
Mailing Address - Country:US
Mailing Address - Phone:949-722-8811
Mailing Address - Fax:
Practice Address - Street 1:2651 IRVINE AVE
Practice Address - Street 2:SUITE 128
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-4628
Practice Address - Country:US
Practice Address - Phone:949-722-8811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-09
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT9274225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant