Provider Demographics
NPI:1063976082
Name:BUDWORTH, SHANNON (PTA)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BUDWORTH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25117 SW PARKWAY AVE
Mailing Address - Street 2:STE D
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1050 E MOUNTAIN VIEW AVE
Practice Address - Street 2:
Practice Address - City:ELLENSBURG
Practice Address - State:WA
Practice Address - Zip Code:98926
Practice Address - Country:US
Practice Address - Phone:509-925-4171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-23
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant