Basic Information
| Provider Information | |||||||||
| NPI: | 1588264550 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THOMPSON | ||||||||
| FirstName: | SHAWN | ||||||||
| MiddleName: | CHEREE | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9229 E 37TH ST N STE 201 | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672262003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166553403 | ||||||||
| FaxNumber: | 3162678191 | ||||||||
| Practice Location | |||||||||
| Address1: | 9229 E 37TH ST N STE 201 | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672262003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166553403 | ||||||||
| FaxNumber: | 3162678191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2020 | ||||||||
| LastUpdateDate: | 10/29/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 14-03776 | KS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 14-03776 | 01 | KS | KANSAS STATE LICENSE | OTHER |