MEDICARE: SHUT ON WAN PT, DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT018413	OH
2	225100000X	Physical Therapist	PT297970	CA

General Provider Information

NPI Number	:	1184263550
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHUT ON WAN PT, DPT

Provider Business Mailing Address
First Line	:	PO BOX 90155
Second Line	:
City	:	CITY OF INDUSTRY
State	:	CA
Zip	:	91715-0155
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1722 DESIRE AVE STE 207
Second Line	:
City	:	ROWLAND HEIGHTS
State	:	CA
Zip	:	91748-2970
Country	:	US
Telephone Number	:	626-965-2229
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/02/2020
Last Update Date	:	12/22/2025

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Directions to “ SHUT ON WAN PT, DPT” Practice Location

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