Provider Demographics
NPI:1922804327
Name:STORK, SHAWN DANIEL (PTA)
Entity type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:DANIEL
Last Name:STORK
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 1:2791 MILLSFIELD HWY
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-1001
Mailing Address - Country:US
Mailing Address - Phone:731-225-2055
Mailing Address - Fax:
Practice Address - Street 1:2035 SAINT JOHN AVE STE 2
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-2247
Practice Address - Country:US
Practice Address - Phone:731-325-5515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-25
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5783225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant