Provider Demographics
NPI:1871803320
Name:RUCKMAN, SHAUN M (PT)
Entity type:Individual
Prefix:
First Name:SHAUN
Middle Name:M
Last Name:RUCKMAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:15543 N REEMS RD
Mailing Address - Street 2:SUITE133
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-9582
Mailing Address - Country:US
Mailing Address - Phone:623-975-5374
Mailing Address - Fax:623-214-9489
Practice Address - Street 1:15543 N REEMS RD
Practice Address - Street 2:SUITE133
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-9582
Practice Address - Country:US
Practice Address - Phone:623-975-5374
Practice Address - Fax:623-214-9489
Is Sole Proprietor?:No
Enumeration Date:2010-10-18
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9056225100000X
2251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic