Healthcare Provider Details

I. General information

NPI: 1912067760
Provider Name (Legal Business Name): SHANE A. VATH SHANE VATH, DSC PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 10/27/2022
Certification Date: 10/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

695 KINKAID RD
ANNAPOLIS MD
21402-1006
US

IV. Provider business mailing address

695 KINKAID RD
ANNAPOLIS MD
21402-1006
US

V. Phone/Fax

Practice location:
  • Phone: 410-293-7981
  • Fax:
Mailing address:
  • Phone: 410-293-7907
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT013186L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: