Provider Demographics
NPI:1780716688
Name:HARDISON, SHAWNA ROSE (PTA)
Entity type:Individual
Prefix:
First Name:SHAWNA
Middle Name:ROSE
Last Name:HARDISON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:SHAWNA
Other - Middle Name:ROSE
Other - Last Name:DOBBINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 831
Mailing Address - Street 2:
Mailing Address - City:MADILL
Mailing Address - State:OK
Mailing Address - Zip Code:73446-0831
Mailing Address - Country:US
Mailing Address - Phone:580-795-3301
Mailing Address - Fax:
Practice Address - Street 1:210 BROOKSIDE DRIVE
Practice Address - Street 2:
Practice Address - City:MADILL
Practice Address - State:OK
Practice Address - Zip Code:73446
Practice Address - Country:US
Practice Address - Phone:580-795-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1263225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant