Provider Demographics
NPI:1912067760
Name:VATH, SHANE A (SHANE VATH, DSC PT)
Entity Type:Individual
Prefix:MR
First Name:SHANE
Middle Name:A
Last Name:VATH
Suffix:
Gender:M
Credentials:SHANE VATH, DSC PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:695 KINKAID RD
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21402-1006
Mailing Address - Country:US
Mailing Address - Phone:410-293-7907
Mailing Address - Fax:
Practice Address - Street 1:695 KINKAID RD
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21402-1006
Practice Address - Country:US
Practice Address - Phone:410-293-7981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT013186L225100000X
VA2305005892171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171000000XOther Service ProvidersMilitary Health Care Provider
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty