Provider Demographics
NPI:1215452719
Name:SHADLE, TANYA (PT, DPT)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:SHADLE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:TANYA
Other - Middle Name:
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15410 S MOUNTAIN PKWY STE 112
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-6691
Mailing Address - Country:US
Mailing Address - Phone:480-706-1161
Mailing Address - Fax:
Practice Address - Street 1:6788 S KINGS RANCH RD STE 4
Practice Address - Street 2:
Practice Address - City:GOLD CANYON
Practice Address - State:AZ
Practice Address - Zip Code:85118-2928
Practice Address - Country:US
Practice Address - Phone:480-982-1909
Practice Address - Fax:480-982-3002
Is Sole Proprietor?:No
Enumeration Date:2017-08-07
Last Update Date:2017-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13166225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist