Provider Demographics
NPI:1053162230
Name:SHAW, DAYNE F (PT, DPT)
Entity type:Individual
Prefix:
First Name:DAYNE
Middle Name:F
Last Name:SHAW
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 N STATE ST STE 5
Mailing Address - Street 2:
Mailing Address - City:SHELLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83274-4900
Mailing Address - Country:US
Mailing Address - Phone:208-428-6079
Mailing Address - Fax:
Practice Address - Street 1:650 N STATE ST STE 5
Practice Address - Street 2:
Practice Address - City:SHELLEY
Practice Address - State:ID
Practice Address - Zip Code:83274-4900
Practice Address - Country:US
Practice Address - Phone:208-428-6079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-27
Last Update Date:2025-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-87692251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics