Provider Demographics
NPI:1942371216
Name:SULLIVAN, SHANE
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8776 E SHEA BLVD
Mailing Address - Street 2:SUITE 106-450
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-6629
Mailing Address - Country:US
Mailing Address - Phone:480-584-3334
Mailing Address - Fax:480-272-9369
Practice Address - Street 1:10133 N 92ND ST STE 101
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-4556
Practice Address - Country:US
Practice Address - Phone:480-584-3334
Practice Address - Fax:480-272-9369
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6673225100000X, 2251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ290315Medicaid
AZ036551Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID