| Doctor Name: | MR. SHANE MICHAEL PETERSON |
| NPI Number: | 1336445535 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | D.P.T. |
| License Number: | 06407 |
| Business Practice Address: | 3300 19th Avenue Forest Grove, OR - 97116 |
| Business Phone Number: | 5033577119 |
| Business Fax Number: | 5039922097 |
| Mailing Address: | #560 Se International Way, Ste. 100 MILWAUKIE |
| State: | OR |
| Postal Code: | 97222 |
| Phone Number: | 9712065200 |
| Fax Number: | 9712065203 |
| NPI Enumeration Date: | 02/04/2011 |
| NPI Last Update Date: | 02/04/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 225100000X |
| License Number: | 06407 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | OR |
| Taxonomy Type: | Respiratory, Developmental, Rehabilitative and Restorative Service Providers |
| Taxonomy Classification: | Physical Therapist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | (1) Physical therapists are health care professionals who evaluate and treat people with health problems resulting from injury or disease. PT |