Provider Demographics
NPI:1306552500
Name:NIETO, SHAUN (PTA)
Entity type:Individual
Prefix:
First Name:SHAUN
Middle Name:
Last Name:NIETO
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4539 HILLSIDE RD
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93636-8013
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:517 S A ST
Practice Address - Street 2:517 S A ST
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93638
Practice Address - Country:US
Practice Address - Phone:559-673-9228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-31
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50075225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant