Basic Information
Provider Information | |||||||||
NPI: | 1558303552 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHUMATE | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 11700 MUKILTEO SPEEDWAY | ||||||||
Address2: | SUITE 503 | ||||||||
City: | MUKILTEO | ||||||||
State: | WA | ||||||||
PostalCode: | 982755432 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4253499692 | ||||||||
FaxNumber: | 4253499694 | ||||||||
Practice Location | |||||||||
Address1: | 11700 MUKILTEO SPEEDWAY | ||||||||
Address2: | SUITE 503 | ||||||||
City: | MUKILTEO | ||||||||
State: | WA | ||||||||
PostalCode: | 982755432 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4253499692 | ||||||||
FaxNumber: | 4253499694 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/12/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X |   |   | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 8904846 | 01 | WA | CRIME VICTIMS | OTHER | 8342156 | 05 | WA |   | MEDICAID | 0195095 | 01 | WA | LABOR & INDUSTRY | OTHER | 5305SH | 01 | WA | REGENCE RIDER # | OTHER | 911745305-98275-A012 | 01 | WA | TRICARE | OTHER | 8342156 | 01 | WA | DSHS | OTHER | 7322199 | 01 | WA | AETNA | OTHER | P00317846 | 01 | WA | RR MEDICARE | OTHER |