Provider Demographics
NPI:1992823264
Name:FOSSEN, SHAD
Entity Type:Individual
Prefix:MR
First Name:SHAD
Middle Name:
Last Name:FOSSEN
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 1:508 AGUA PL
Mailing Address - Street 2:
Mailing Address - City:SEAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90740-6216
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:456 ELM AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802-2426
Practice Address - Country:US
Practice Address - Phone:562-437-6717
Practice Address - Fax:562-590-6012
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2013-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner