Healthcare Provider Details

I. General information

NPI: 1023788932
Provider Name (Legal Business Name): SHANNON MORELAND PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2021
Last Update Date: 09/14/2021
Certification Date: 08/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 4TH ST
KREMMLING CO
80459
US

IV. Provider business mailing address

485 MEADOW WOOD CIR
DILLON CO
80435-8485
US

V. Phone/Fax

Practice location:
  • Phone: 970-724-3442
  • Fax:
Mailing address:
  • Phone: 316-992-2505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberPTA.0014974
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: