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General NPI Number Information
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NPI Number | 1144784471
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Entity Type | Individual
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Provider Name | SHANNON GOLTL ATC
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Gender | Female
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Dates
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Enumeration Date | 01/31/2019
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Last Update Date | 06/28/2020
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Provider Practice Location Address
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Address Line | 2500 OLD HIGHWAY 63 S APT 7113
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City | COLUMBIA
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State | MO
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Zip | 65201-2203
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Country | US
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Telephone | 720-829-7575
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Fax |
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Provider Business Mailing Address
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Address Line | 5306 SILVER MILL DR
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City | COLUMBIA
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State | MO
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Zip | 65202-6593
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 2000038556
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License Number State | MO
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