Healthcare Provider Details

I. General information

NPI: 1265113450
Provider Name (Legal Business Name): SHAUN DOUGLASS PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2023
Last Update Date: 02/04/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7767 ELM CREEK BLVD N STE 160
MAPLE GROVE MN
55369-7078
US

IV. Provider business mailing address

6145 MACLYNN AVE NE
OTSEGO MN
55301-4589
US

V. Phone/Fax

Practice location:
  • Phone: 763-201-8191
  • Fax:
Mailing address:
  • Phone: 763-213-5505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA1923
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: