Provider Demographics
NPI:1588435648
Name:ROSTUCHER, SHAWN EDWARD
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:EDWARD
Last Name:ROSTUCHER
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 1:3429 SALMON ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19134-6014
Mailing Address - Country:US
Mailing Address - Phone:267-606-8886
Mailing Address - Fax:
Practice Address - Street 1:3429 SALMON ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19134-6014
Practice Address - Country:US
Practice Address - Phone:267-606-8886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-09
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA329729952255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer