Provider Demographics
NPI:1730444555
Name:PROSSER, SHAWN ERLENE (PTA)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:ERLENE
Last Name:PROSSER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:SHAWN
Other - Middle Name:ERLENE
Other - Last Name:RAHE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:7451 SE ANDERSON LANE
Mailing Address - Street 2:
Mailing Address - City:LATHROP
Mailing Address - State:MO
Mailing Address - Zip Code:64465
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7451 SE ANDERSON LN
Practice Address - Street 2:
Practice Address - City:LATHROP
Practice Address - State:MO
Practice Address - Zip Code:64465-8586
Practice Address - Country:US
Practice Address - Phone:785-741-0621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-09
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008027451225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2008027451Medicare PIN