Healthcare Provider Details

I. General information

NPI: 1033170725
Provider Name (Legal Business Name): SHANE DAVIS P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 06/27/2025
Certification Date: 06/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13040 STATE ROUTE 12
BOONVILLE NY
13309-4942
US

IV. Provider business mailing address

13040 STATE ROUTE 12
BOONVILLE NY
13309-4942
US

V. Phone/Fax

Practice location:
  • Phone: 315-358-4028
  • Fax: 315-358-4394
Mailing address:
  • Phone: 315-358-4028
  • Fax: 315-358-4186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number022935
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: