Provider Demographics
NPI:1992529556
Name:PORTER, SHAUN (PT, DPT)
Entity type:Individual
Prefix:
First Name:SHAUN
Middle Name:
Last Name:PORTER
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S VILLA SAN MARCO DR # 3-306
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-4124
Mailing Address - Country:US
Mailing Address - Phone:423-367-1679
Mailing Address - Fax:
Practice Address - Street 1:733 DUNLAWTON AVE STE 103
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-4226
Practice Address - Country:US
Practice Address - Phone:386-756-0077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-11
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL42478225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist