Provider Demographics
NPI:1285722421
Name:SHUPE, SARA L (PT)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:L
Last Name:SHUPE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7541 9TH ST N
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-6626
Mailing Address - Country:US
Mailing Address - Phone:651-748-4338
Mailing Address - Fax:
Practice Address - Street 1:4465 WHITE BEAR PKWY
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-7623
Practice Address - Country:US
Practice Address - Phone:651-653-1350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6986225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN323064300Medicaid
MN323064300Medicaid