Provider Demographics
NPI:1457188252
Name:SHIN, TAE SUB
Entity type:Individual
Prefix:MR
First Name:TAE
Middle Name:SUB
Last Name:SHIN
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 1:506 SANTEE DRIVE
Mailing Address - Street 2:
Mailing Address - City:SPOTSYLVANIA
Mailing Address - State:VA
Mailing Address - Zip Code:22551
Mailing Address - Country:US
Mailing Address - Phone:804-241-5151
Mailing Address - Fax:
Practice Address - Street 1:506 SANTEE DRIVE
Practice Address - Street 2:
Practice Address - City:SPOTSYLVANIA
Practice Address - State:VA
Practice Address - Zip Code:22551
Practice Address - Country:US
Practice Address - Phone:804-241-5151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019010730225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist