MEDICARE: SHANNON BOUSHEHRI PT, DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	306394	CA

General Provider Information

NPI Number	:	1346073988
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON BOUSHEHRI PT, DPT

Provider Business Mailing Address
First Line	:	3959 RUFFIN RD STE J
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-1830
Country	:	US
Telephone Number	:	858-279-5570
Fax Number	:

Provider Business Practice Location Address
First Line	:	3323 CARMEL MOUNTAIN RD STE 200
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92121-1035
Country	:	US
Telephone Number	:	858-720-0991
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/20/2024
Last Update Date	:	08/20/2024

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