=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225341308
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREW BRETT SHAFFER ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2010
-----------------------------------------------------
Last Update Date | 07/19/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8227 NORTHWEST BLVD STE 160
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46278-1386
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-415-5747
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1009 FROGS LEAP
-----------------------------------------------------
City | CICERO
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46034-9136
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-210-0673
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 36001038A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------