Provider Demographics
NPI:1699958074
Name:SHAW, LESLIE A (PTA)
Entity type:Individual
Prefix:MR
First Name:LESLIE
Middle Name:A
Last Name:SHAW
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14910 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ALACHUA
Mailing Address - State:FL
Mailing Address - Zip Code:32615-8591
Mailing Address - Country:US
Mailing Address - Phone:352-462-1843
Mailing Address - Fax:
Practice Address - Street 1:14910 MAIN ST
Practice Address - Street 2:
Practice Address - City:ALACHUA
Practice Address - State:FL
Practice Address - Zip Code:32615-8591
Practice Address - Country:US
Practice Address - Phone:352-462-1843
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-09
Last Update Date:2007-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21098225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant