Provider Demographics
NPI:1679391759
Name:SHIN, JISUK (PTA)
Entity type:Individual
Prefix:
First Name:JISUK
Middle Name:
Last Name:SHIN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:REINNA
Other - Middle Name:
Other - Last Name:SHIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:315 WALT WHITMAN RD STE 214
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-4112
Mailing Address - Country:US
Mailing Address - Phone:631-923-0334
Mailing Address - Fax:631-923-0335
Practice Address - Street 1:315 WALT WHITMAN RD STE 214
Practice Address - Street 2:
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-4112
Practice Address - Country:US
Practice Address - Phone:631-923-0334
Practice Address - Fax:631-923-0335
Is Sole Proprietor?:No
Enumeration Date:2024-09-28
Last Update Date:2024-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant