Provider Demographics
NPI:1356391692
Name:LY, SHAI T (DPT)
Entity type:Individual
Prefix:MR
First Name:SHAI
Middle Name:T
Last Name:LY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1537 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-2407
Mailing Address - Country:US
Mailing Address - Phone:760-591-7750
Mailing Address - Fax:760-410-0140
Practice Address - Street 1:9909 MIRA MESA BLVD
Practice Address - Street 2:STE. 120
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92131-1056
Practice Address - Country:US
Practice Address - Phone:858-693-0436
Practice Address - Fax:858-693-0437
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT29707CMedicare ID - Type Unspecified
CAWPT29707AMedicare ID - Type Unspecified
CAWPT29707BMedicare ID - Type Unspecified
CAWPT29707DMedicare ID - Type Unspecified