Basic Information
| Provider Information | |||||||||
| NPI: | 1033474432 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHUPE | ||||||||
| FirstName: | ASHLEE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT, DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FIELDS | ||||||||
| OtherFirstName: | ASHLEE | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT, DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 390 LINCOLN ST STE 230 | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974016021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412552095 | ||||||||
| FaxNumber: | 5412552445 | ||||||||
| Practice Location | |||||||||
| Address1: | 390 LINCOLN ST STE 230 | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974016021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412552095 | ||||||||
| FaxNumber: | 5412552445 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2012 | ||||||||
| LastUpdateDate: | 01/09/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 9855PT | AZ | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 12409672 | 01 | AZ | CAQH | OTHER |