Basic Information
| Provider Information | |||||||||
| NPI: | 1881015642 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOEKE | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | N5532 WINNVUE CT | ||||||||
| Address2: | |||||||||
| City: | FOND DU LAC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549379639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209042252 | ||||||||
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| Practice Location | |||||||||
| Address1: | 115 E ARNDT ST | ||||||||
| Address2: | |||||||||
| City: | FOND DU LAC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549352461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209237040 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2013 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | 12571-24 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.