Provider Demographics
NPI:1265113450
Name:DOUGLASS, SHAUN (PTA)
Entity type:Individual
Prefix:
First Name:SHAUN
Middle Name:
Last Name:DOUGLASS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6145 MACLYNN AVE NE
Mailing Address - Street 2:
Mailing Address - City:OTSEGO
Mailing Address - State:MN
Mailing Address - Zip Code:55301-4589
Mailing Address - Country:US
Mailing Address - Phone:763-213-5505
Mailing Address - Fax:
Practice Address - Street 1:7767 ELM CREEK BLVD N STE 160
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-7078
Practice Address - Country:US
Practice Address - Phone:763-201-8191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-31
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA1923225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant