Provider Demographics
NPI:1932732369
Name:CONNOR, SHANE
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:CONNOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:158 OVERLOOK DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08809-1109
Mailing Address - Country:US
Mailing Address - Phone:267-885-5854
Mailing Address - Fax:
Practice Address - Street 1:1445 BENTLEY DR
Practice Address - Street 2:
Practice Address - City:WARRINGTON
Practice Address - State:PA
Practice Address - Zip Code:18976-1350
Practice Address - Country:US
Practice Address - Phone:267-885-5854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-13
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305216110225100000X
PAPT028251225100000X
KY007919225100000X
GAPT016973225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist