Provider Demographics
NPI:1770571085
Name:SHUPE, DAVID WAYNE (PT)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:WAYNE
Last Name:SHUPE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4728 CAPITOL ST
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-1867
Mailing Address - Country:US
Mailing Address - Phone:605-721-7733
Mailing Address - Fax:605-342-9592
Practice Address - Street 1:2050 W MAIN ST
Practice Address - Street 2:#4
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-0905
Practice Address - Country:US
Practice Address - Phone:605-342-9575
Practice Address - Fax:605-342-9592
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD135225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD4998962OtherWELLMARK
SD5830732Medicaid
SD4998962OtherWELLMARK