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General NPI Number Information
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NPI Number | 1427663251
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Entity Type | Individual
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Provider Name | DEVON MICHELLE SHAUT
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Gender | Female
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Dates
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Enumeration Date | 09/09/2020
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Last Update Date | 09/09/2020
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Provider Practice Location Address
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Address Line | 3000 FREDERICA ST
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City | OWENSBORO
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State | KY
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Zip | 42301-4230
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Country | US
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Telephone | 651-270-3801
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Fax |
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Provider Business Mailing Address
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Address Line | 3000 FREDERICA ST ATHLETIC TRAINING ROOM
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City | OWENSBORO
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State | KY
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Zip | 42301
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Country | US
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Telephone | 651-270-3801
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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 | 2083S0010X
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Taxonomy Name | Sports Medicine (Preventive Medicine) Physician
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License Number | 2000039774
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License Number State | KY
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