Provider Demographics
NPI:1366908675
Name:KING, SHAWN A
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:A
Last Name:KING
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10362 OLD OLIVE STREET RD APT 212
Mailing Address - Street 2:
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-5936
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:637 DUNN RD
Practice Address - Street 2:
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-1747
Practice Address - Country:US
Practice Address - Phone:314-731-4555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-12
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic