Basic Information
| Provider Information | |||||||||
| NPI: | 1841526258 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | O'CONNELL | ||||||||
| FirstName: | SHAWN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12121 HARBOUR REACH DR | ||||||||
| Address2: | BUILDING A - STE 100 | ||||||||
| City: | MUKILTEO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982755314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254938313 | ||||||||
| FaxNumber: | 4254939614 | ||||||||
| Practice Location | |||||||||
| Address1: | 10505 19TH AVE SE | ||||||||
| Address2: | STE B | ||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982084280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4085700510 | ||||||||
| FaxNumber: | 4089454018 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2009 | ||||||||
| LastUpdateDate: | 01/25/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT60100585 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | G8894942 | 01 | WA | MEDICARE | OTHER |