Healthcare Provider Details

I. General information

NPI: 1922158377
Provider Name (Legal Business Name): SHAWN D AXTEN PT,CST-D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 06/19/2024
Certification Date: 06/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20360 EMPIRE AVE # B-9A
BEND OR
97703-5709
US

IV. Provider business mailing address

PO BOX 444
BEND OR
97709-0444
US

V. Phone/Fax

Practice location:
  • Phone: 360-607-7226
  • Fax: 541-706-9330
Mailing address:
  • Phone: 360-607-7226
  • Fax: 541-706-9330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P0010X
TaxonomyPediatric Rehabilitation Medicine Physician
License NumberWAPT0000574
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number01557
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: