Healthcare Provider Details

I. General information

NPI: 1700039401
Provider Name (Legal Business Name): JOHN T SHLIAPA ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2008
Last Update Date: 10/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 SUNSET LN
PAXTON MA
01612-1106
US

IV. Provider business mailing address

274 SAINT NICHOLAS AVE
WORCESTER MA
01606-1811
US

V. Phone/Fax

Practice location:
  • Phone: 508-849-3595
  • Fax:
Mailing address:
  • Phone: 508-849-3595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1918
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: