Provider Demographics
NPI:1295063436
Name:IVERSON, SHARON ROSE (PT)
Entity type:Individual
Prefix:
First Name:SHARON
Middle Name:ROSE
Last Name:IVERSON
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 1:17345 72ND PL N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-4553
Mailing Address - Country:US
Mailing Address - Phone:763-226-3405
Mailing Address - Fax:
Practice Address - Street 1:3130 GRIMES AVE N
Practice Address - Street 2:
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-3217
Practice Address - Country:US
Practice Address - Phone:763-450-2737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-30
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3072225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist