=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417365255
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ASHLEY SHAM MS, LAT, ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2014
-----------------------------------------------------
Last Update Date | 07/24/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2360 HIGHLAND RD
-----------------------------------------------------
City | HERMITAGE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16148-2819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-983-5444
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2360 HIGHLAND RD
-----------------------------------------------------
City | HERMITAGE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16148-2819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-983-5444
-----------------------------------------------------
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 | RT003580
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------