Healthcare Provider Details

I. General information

NPI: 1891789418
Provider Name (Legal Business Name): NED SHANNON LAT ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 E HANNA AVE
INDIANAPOLIS IN
46227-3630
US

IV. Provider business mailing address

1400 E HANNA AVE
INDIANAPOLIS IN
46227-3630
US

V. Phone/Fax

Practice location:
  • Phone: 317-788-6112
  • Fax: 317-788-3472
Mailing address:
  • Phone: 317-788-6112
  • Fax: 317-788-3472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36000055A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: