Provider Demographics
NPI:1508605478
Name:BOSTELMAN, SHANE (DPT)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:BOSTELMAN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:H059 STATE ROUTE 65
Mailing Address - Street 2:
Mailing Address - City:DESHLER
Mailing Address - State:OH
Mailing Address - Zip Code:43516-9725
Mailing Address - Country:US
Mailing Address - Phone:419-966-7464
Mailing Address - Fax:
Practice Address - Street 1:3100 OLYMPUS BLVD. SUITE 500
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75019
Practice Address - Country:US
Practice Address - Phone:419-966-7464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-21
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT018015225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist