Provider Demographics
NPI:1245481613
Name:SHANE, MATTHEW ROBERT (DPT)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:ROBERT
Last Name:SHANE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 W STATE HIGHWAY 6 STE G
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-5584
Mailing Address - Country:US
Mailing Address - Phone:254-300-1941
Mailing Address - Fax:
Practice Address - Street 1:331 W STATE HIGHWAY 6 STE G
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-5584
Practice Address - Country:US
Practice Address - Phone:254-300-1941
Practice Address - Fax:254-875-0472
Is Sole Proprietor?:No
Enumeration Date:2008-10-03
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1204921225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist