Provider Demographics
NPI:1508737073
Name:LASSITER, SHADERRE
Entity type:Individual
Prefix:
First Name:SHADERRE
Middle Name:
Last Name:LASSITER
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 1:423 SCOTT ST APT 2
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702-5539
Mailing Address - Country:US
Mailing Address - Phone:888-510-2095
Mailing Address - Fax:
Practice Address - Street 1:182 BUTLER ST
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-4465
Practice Address - Country:US
Practice Address - Phone:888-510-2095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-16
Last Update Date:2025-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA611332251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic