Provider Demographics
NPI:1285272377
Name:EDMONDSON, SHANE LEE (PT, DPT)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:LEE
Last Name:EDMONDSON
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 CANYON DR
Mailing Address - Street 2:
Mailing Address - City:HIDEAWAY
Mailing Address - State:TX
Mailing Address - Zip Code:75771-5040
Mailing Address - Country:US
Mailing Address - Phone:903-292-9183
Mailing Address - Fax:
Practice Address - Street 1:5407 NEW COPELAND RD STE 100
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-3997
Practice Address - Country:US
Practice Address - Phone:903-630-7204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-19
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist