Healthcare Provider Details

I. General information

NPI: 1942371216
Provider Name (Legal Business Name): SHANE SULLIVAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2006
Last Update Date: 02/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10133 N 92ND ST STE 101
SCOTTSDALE AZ
85258-4556
US

IV. Provider business mailing address

8776 E SHEA BLVD SUITE 106-450
SCOTTSDALE AZ
85260-6629
US

V. Phone/Fax

Practice location:
  • Phone: 480-584-3334
  • Fax: 480-272-9369
Mailing address:
  • Phone: 480-584-3334
  • Fax: 480-272-9369

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number6673
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number6673
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: