Provider Demographics
NPI:1184263550
Name:WAN, SHUT ON (PT, DPT)
Entity type:Individual
Prefix:
First Name:SHUT ON
Middle Name:
Last Name:WAN
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1722 DESIRE AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:ROWLAND HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91748-2970
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1722 DESIRE AVE STE 203
Practice Address - Street 2:
Practice Address - City:ROWLAND HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:91748-2970
Practice Address - Country:US
Practice Address - Phone:626-965-2229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-02
Last Update Date:2020-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT018413225100000X
CAPT297970225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist