Provider Demographics
NPI:1982825873
Name:HERBER, SHANNON KAY
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:KAY
Last Name:HERBER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:KAY
Other - Last Name:HERBER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:27005 PACIFIC HIGHWAY SOUTH
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:WA
Mailing Address - Zip Code:98198
Mailing Address - Country:US
Mailing Address - Phone:253-839-9280
Mailing Address - Fax:
Practice Address - Street 1:27005 PACIFIC HIGHWAY SOUTH
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:WA
Practice Address - Zip Code:98198
Practice Address - Country:US
Practice Address - Phone:253-839-9280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA50-6570Medicare ID - Type UnspecifiedMEDICARE