Provider Demographics
NPI:1205120920
Name:WEBER, SHANE MICHAEL (DPT)
Entity type:Individual
Prefix:MR
First Name:SHANE
Middle Name:MICHAEL
Last Name:WEBER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1674 15TH STREET WEST
Mailing Address - Street 2:SUITE #1
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1674 15TH STREET WEST
Practice Address - Street 2:SUITE #1
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601
Practice Address - Country:US
Practice Address - Phone:701-483-8686
Practice Address - Fax:701-483-8644
Is Sole Proprietor?:No
Enumeration Date:2011-05-31
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1626225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist