Basic Information
| Provider Information | |||||||||
| NPI: | 1215452719 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHADLE | ||||||||
| FirstName: | TANYA | ||||||||
| MiddleName: | |||||||||
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| Credential: | PT, DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LEE | ||||||||
| OtherFirstName: | TANYA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 15410 S MOUNTAIN PKWY STE 112 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850446691 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807061161 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6788 S KINGS RANCH RD STE 4 | ||||||||
| Address2: | |||||||||
| City: | GOLD CANYON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 851182928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809821909 | ||||||||
| FaxNumber: | 4809823002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2017 | ||||||||
| LastUpdateDate: | 08/07/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 13166 | AZ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.