Healthcare Provider Details

I. General information

NPI: 1881068286
Provider Name (Legal Business Name): TRAVIS SHAWN NOLAN LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2015
Last Update Date: 03/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2902 S ZENITH CIR
SALT LAKE CITY UT
84106-2131
US

IV. Provider business mailing address

2368 E REDONDO AVE
SALT LAKE CITY UT
84108-3259
US

V. Phone/Fax

Practice location:
  • Phone: 802-373-1016
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number9436553-4810
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: