Provider Demographics
NPI:1144501305
Name:ANTHONY, SHANE MICHAEL (PTA)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:MICHAEL
Last Name:ANTHONY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:
Practice Address - Street 1:1025 E WEST CONNECTOR
Practice Address - Street 2:STE. 406
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-8513
Practice Address - Country:US
Practice Address - Phone:770-384-1001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-01
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA000604225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant