Healthcare Provider Details

I. General information

NPI: 1770575557
Provider Name (Legal Business Name): THOMAS SHELTON LAT, ATC, RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: TC SHELTON LAT, ATC, APRN, FNP-

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 09/26/2022
Certification Date: 09/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 N 8TH AVE STE 1B
DILLON SC
29536-2549
US

IV. Provider business mailing address

PO BOX 3239
FLORENCE SC
29502-3239
US

V. Phone/Fax

Practice location:
  • Phone: 843-487-1588
  • Fax: 843-487-1590
Mailing address:
  • Phone: 843-487-1588
  • Fax: 843-487-1590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR103177
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT 277
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number125715
License Number StateAR
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26521
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: