Provider Demographics
NPI:1255348462
Name:SHADDUCK, KRISTIN TYSE (PT)
Entity type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:TYSE
Last Name:SHADDUCK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:794 ALTOS OAKS DR
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94024-6013
Mailing Address - Country:US
Mailing Address - Phone:650-947-9646
Mailing Address - Fax:650-947-9566
Practice Address - Street 1:794 ALTOS OAKS DR
Practice Address - Street 2:
Practice Address - City:LOS ALTOS
Practice Address - State:CA
Practice Address - Zip Code:94024-6013
Practice Address - Country:US
Practice Address - Phone:650-947-9646
Practice Address - Fax:650-947-9566
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11542225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACG5266OtherRAILROAD MEDICARE
CAZZZ555752OtherBLUE SHIELD
CACG5266OtherRAILROAD MEDICARE