Healthcare Provider Details

I. General information

NPI: 1003066853
Provider Name (Legal Business Name): SHANE MARLON PEDERSON P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2008
Last Update Date: 07/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 WEST MILE 3 ROAD SUITE A-103
PALMHURST TX
78573
US

IV. Provider business mailing address

123 WEST MILE 3 ROAD SUITE A-103
PALMHURST TX
78573
US

V. Phone/Fax

Practice location:
  • Phone: 956-585-9889
  • Fax: 956-585-9896
Mailing address:
  • Phone: 956-585-9889
  • Fax: 956-585-9896

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1155757
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: