Provider Demographics
NPI:1982028072
Name:SMITH, SHANE
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:SMITH
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 1:1575 PINE RIDGE RD
Mailing Address - Street 2:SUITE 15
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34109-2107
Mailing Address - Country:US
Mailing Address - Phone:239-593-4348
Mailing Address - Fax:239-593-4387
Practice Address - Street 1:1575 PINE RIDGE RD
Practice Address - Street 2:SUITE 15
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109-2107
Practice Address - Country:US
Practice Address - Phone:239-593-4348
Practice Address - Fax:239-593-4387
Is Sole Proprietor?:No
Enumeration Date:2014-02-10
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT28915225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFF459AMedicare PIN