MEDICARE: RASIDAT TAIWO SHOGE

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	225200000X	Physical Therapy Assistant	2306604768	VA

General Provider Information

NPI Number	:	1548770001
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RASIDAT TAIWO SHOGE

Provider Business Mailing Address
First Line	:	1645 HIGH PLAINS DR
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-8508
Country	:	US
Telephone Number	:	862-235-9631
Fax Number	:

Provider Business Practice Location Address
First Line	:	1645 HIGH PLAINS DR
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-8508
Country	:	US
Telephone Number	:	862-235-9631
Fax Number	:

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

Provider Enumeration Date	:	10/10/2017
Last Update Date	:	10/10/2017

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Directions to “ RASIDAT TAIWO SHOGE ” Practice Location

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