MEDICARE: MS. SUSAN KAY SHELTON PTA

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	225200000X	Physical Therapy Assistant	160001014	IL

General Provider Information

NPI Number	:	1346558343
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SUSAN KAY SHELTON PTA

Provider Business Mailing Address
First Line	:	17510 HILL WAY
Second Line	:
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97035-5414
Country	:	US
Telephone Number	:	503-686-9592
Fax Number	:

Provider Business Practice Location Address
First Line	:	17510 HILL WAY
Second Line	:
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97035-5414
Country	:	US
Telephone Number	:	503-686-9592
Fax Number	:

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

Provider Enumeration Date	:	09/24/2010
Last Update Date	:	09/24/2010

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