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General NPI Number Information
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NPI Number | 1699020305
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Entity Type | Individual
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Provider Name | MICHAEL SHANE GOSNELL PT, DPT
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Gender | Male
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Dates
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Enumeration Date | 07/18/2012
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Last Update Date | 07/18/2012
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Provider Practice Location Address
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Address Line | 804 S 16TH ST
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City | MATTOON
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State | IL
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Zip | 61938-5620
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Country | US
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Telephone | 217-460-0910
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Fax |
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Provider Business Mailing Address
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Address Line | 804 S 16TH ST
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City | MATTOON
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State | IL
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Zip | 61938-5620
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Country | US
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Telephone | 217-460-0910
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 070018869
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License Number State | IL
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