Provider Demographics
NPI:1649427733
Name:RIESTER, SHAWN PATRICK (DPT)
Entity type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:PATRICK
Last Name:RIESTER
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 1:2801 WEHRLE DR STE 12
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-7381
Mailing Address - Country:US
Mailing Address - Phone:716-818-0172
Mailing Address - Fax:
Practice Address - Street 1:2801 WEHRLE DR STE 12
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-7381
Practice Address - Country:US
Practice Address - Phone:716-818-0172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-20
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030457225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400001667Medicare PIN