Provider Demographics
NPI:1063487098
Name:MAINS, SHAWN LEE (PT)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:LEE
Last Name:MAINS
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 1:909 S WASHBURN ST
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54904-8051
Mailing Address - Country:US
Mailing Address - Phone:920-235-8966
Mailing Address - Fax:920-235-1526
Practice Address - Street 1:909 S WASHBURN ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904-8051
Practice Address - Country:US
Practice Address - Phone:920-235-8966
Practice Address - Fax:920-235-1526
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4369-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40221500Medicaid
WI000086635 0005Medicare ID - Type Unspecified