Shane Bradley Wall, PT – Physical Therapist

Key facts

NPI: 1992287619
Entity type: Individual (NPI type 1)
Primary specialty: Physical Therapist 225100000X
License: 1125359 (TX)
Practice address: 400 S Houston St
De Leon, TX 76444-1928
Phone: (254) 893-2015
NPI assigned: Aug 29, 2018
Sex: Male
Sole proprietor: No

Organizations & group practices 1

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Northwest Physical Therapy Inc Physical Therapist · Azle, TX · NPI 1114507852

Medicare reassignment NPD Authorized official PHYSICAL THERAPIST · TX

Medicare Care Compare profile

Specialty: Physical Therapist in Private Practice
Education: Other, 1997
Medicare assignment: Accepts the Medicare-approved amount as payment in full

Practice addresses (Care Compare)

408 Central Dr
Azle, TX 76020-3140
Phone (817) 444-8827

Medicare participation

Medicare fee-for-service enrollment: Enrolled in TX

Medicare enrollment records

Enrollment ID	State	Provider type	PAC ID	Details
I20210526000048	TX	Practitioner - Physical Therapist in Private Practice	7113326083	Reassigns benefits to 1 organization

National Provider Directory

Medicare enrollment (NPD): Yes

Practice roles

Organization	Specialty	Status	New patients
Northwest Physical Therapy Inc	Physical Therapist	Current since Oct 1, 2021	Accepting new patients

Locations

408 Central Dr
Azle, TX 76020
Phone (817) 444-8827

Specialties & licenses

Specialty (taxonomy)	Code	License	State	Primary
Physical Therapist	225100000X	1125359	TX	Yes

Addresses

Primary practice location

400 S Houston St
De Leon, TX 76444-1928

Mailing address

400 S Houston St.
De Leon, TX 76444
Phone (254) 893-2015

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Sep 4, 2020.

{
    "created_epoch": "1535500800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1599177600000",
    "number": "1992287619",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "400 S HOUSTON ST.",
            "city": "DE LEON",
            "state": "TX",
            "postal_code": "76444",
            "telephone_number": "254-893-2015"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "400 S HOUSTON ST",
            "city": "DE LEON",
            "state": "TX",
            "postal_code": "764441928",
            "telephone_number": "254-893-2015"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALL",
        "first_name": "SHANE",
        "middle_name": "BRADLEY",
        "credential": "PT",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2018-08-29",
        "last_updated": "2020-09-04",
        "certification_date": "2020-09-04",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "TX",
            "license": "1125359",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in De Leon, TX

All providers in De Leon, TX · Physical Therapist in Texas

Sources for this page

NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Sep 4, 2020. Information in NPPES is self-reported and not verified by CMS.
NUCC Health Care Provider Taxonomy: specialty names.
Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.