Healthcare Provider Details

I. General information

NPI: 1912952219
Provider Name (Legal Business Name): SHAUN A. KOTH P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 06/17/2025
Certification Date: 06/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16968 W BELL RD # D401
SURPRISE AZ
85374-8943
US

IV. Provider business mailing address

14287 N 87TH ST STE 220
SCOTTSDALE AZ
85260-3698
US

V. Phone/Fax

Practice location:
  • Phone: 623-299-9190
  • Fax: 623-299-9191
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number4108
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: