Provider Demographics
NPI:1316457310
Name:URBAN, SHANNON MARIE (PT, DPT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:URBAN
Suffix:
Gender:F
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 1:200 TUCKERTON RD STE 17
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08055-8806
Mailing Address - Country:US
Mailing Address - Phone:856-396-2250
Mailing Address - Fax:
Practice Address - Street 1:200 TUCKERTON RD STE 17
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NJ
Practice Address - Zip Code:08055-8806
Practice Address - Country:US
Practice Address - Phone:856-396-2250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-04
Last Update Date:2023-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA017551002251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic