Provider Demographics
NPI:1104485168
Name:POGUE, SHANNA LEA (PTA)
Entity type:Individual
Prefix:MRS
First Name:SHANNA
Middle Name:LEA
Last Name:POGUE
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 1:19156 W ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68135-4298
Mailing Address - Country:US
Mailing Address - Phone:402-203-7743
Mailing Address - Fax:
Practice Address - Street 1:4330 S 144TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-1051
Practice Address - Country:US
Practice Address - Phone:402-614-4000
Practice Address - Fax:402-885-6897
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-12
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NENE151225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NENE151Medicaid