Provider Demographics
NPI:1487100376
Name:SHOCKMAN, LANE MARTY (PTA)
Entity type:Individual
Prefix:
First Name:LANE
Middle Name:MARTY
Last Name:SHOCKMAN
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 1:600 N.W 11TH
Mailing Address - Street 2:SUITE E31
Mailing Address - City:HERMISTON
Mailing Address - State:OR
Mailing Address - Zip Code:97838
Mailing Address - Country:US
Mailing Address - Phone:541-667-3657
Mailing Address - Fax:541-667-3659
Practice Address - Street 1:600 NW 11TH ST
Practice Address - Street 2:SUITE E31
Practice Address - City:HERMISTON
Practice Address - State:OR
Practice Address - Zip Code:97838-8605
Practice Address - Country:US
Practice Address - Phone:541-667-3657
Practice Address - Fax:541-667-3659
Is Sole Proprietor?:No
Enumeration Date:2016-08-30
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR09190225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant