Healthcare Provider Details

I. General information

NPI: 1326522038
Provider Name (Legal Business Name): SHANE WEBER PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2018
Last Update Date: 09/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1902 59TH ST W
BRADENTON FL
34209-4602
US

IV. Provider business mailing address

11826 BROOKSIDE DR
LAKEWOOD RANCH FL
34211-4527
US

V. Phone/Fax

Practice location:
  • Phone: 941-761-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA21756
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: