=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730596586
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERICKA SHAFER LAT, MS, ATC, CES
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2014
-----------------------------------------------------
Last Update Date | 07/14/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3200 COLLEGE AVE
-----------------------------------------------------
City | BEAVER FALLS
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15010-3557
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-847-6654
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3200 COLLEGE AVE
-----------------------------------------------------
City | BEAVER FALLS
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15010-3557
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-847-6654
-----------------------------------------------------
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 | TR005156
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------