Healthcare Provider Details

I. General information

NPI: 1770829897
Provider Name (Legal Business Name): MICHELLE YANGYANG SHI MD, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: YANGYANG SHI DPT

II. Dates (important events)

Enumeration Date: 12/17/2012
Last Update Date: 06/15/2022
Certification Date: 06/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 COMMUNITY DR
MANHASSET NY
11030-3816
US

IV. Provider business mailing address

300 COMMUNITY DR
MANHASSET NY
11030-3816
US

V. Phone/Fax

Practice location:
  • Phone: 516-562-0100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number035761
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number317304
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier5436026
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: