Provider Demographics
NPI:1174754956
Name:COLE, SHAWN ISHMAEL (PTA)
Entity type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:ISHMAEL
Last Name:COLE
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 1:5 POMONA AVE
Mailing Address - Street 2:APT 2H
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07112-2300
Mailing Address - Country:US
Mailing Address - Phone:973-392-2320
Mailing Address - Fax:
Practice Address - Street 1:5 POMONA AVE
Practice Address - Street 2:APT 2H
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07112-2300
Practice Address - Country:US
Practice Address - Phone:973-392-2320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-28
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00265900225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ40QB00265900OtherPTA LICENCE #