Provider Demographics
NPI:1427705912
Name:SHAW, BENJAMIN GEORGE (PT, DPT)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:GEORGE
Last Name:SHAW
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 1:2111 FIX RD
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:14072-2547
Mailing Address - Country:US
Mailing Address - Phone:716-864-7929
Mailing Address - Fax:
Practice Address - Street 1:1 COLOMBA DR STE 5
Practice Address - Street 2:
Practice Address - City:NIAGARA FALLS
Practice Address - State:NY
Practice Address - Zip Code:14305-1275
Practice Address - Country:US
Practice Address - Phone:716-298-2249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-04
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047686225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist