Provider Demographics
NPI:1144264284
Name:SHAW, JONATHAN THOMAS (MSPT)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:THOMAS
Last Name:SHAW
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8125 BOWERMAN RD
Mailing Address - Street 2:
Mailing Address - City:HORTON
Mailing Address - State:MI
Mailing Address - Zip Code:49246-9522
Mailing Address - Country:US
Mailing Address - Phone:517-795-0321
Mailing Address - Fax:
Practice Address - Street 1:3220 DUNWOODIE RD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-4113
Practice Address - Country:US
Practice Address - Phone:734-717-1690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2009-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011233225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP03660002Medicare ID - Type UnspecifiedPHYSICAL THERAPY