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General NPI Number Information
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NPI Number | 1851918247
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Entity Type | Individual
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Provider Name | SHANE M CHIASSON
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Gender | Male
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Dates
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Enumeration Date | 07/01/2020
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Last Update Date | 07/01/2020
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Provider Practice Location Address
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Address Line | 726 N ACADIA RD
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City | THIBODAUX
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State | LA
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Zip | 70301-5051
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Country | US
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Telephone | 985-493-4502
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Fax |
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Provider Business Mailing Address
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Address Line | 162 HARVEST CT
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City | THIBODAUX
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State | LA
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Zip | 70301-3988
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Country | US
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Telephone |
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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 | ATH.200421
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License Number State | LA
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