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General NPI Number Information
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NPI Number | 1801855440
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Entity Type | Individual
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Provider Name | SHANNON D CAMPBELL ATC/L
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Gender | Male
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Dates
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Enumeration Date | 03/22/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1114 9TH AVE
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City | LEWISTON
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State | ID
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Zip | 83501-2659
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Country | US
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Telephone | 208-748-3102
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Fax |
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Provider Business Mailing Address
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Address Line | 330 N GRANT ST
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City | MOSCOW
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State | ID
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Zip | 83843-3674
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Country | US
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Telephone | 208-882-3239
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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 | AT-067
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License Number State | ID
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