MEDICARE: SHANNON GOLTL ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	2000038556	MO

General Provider Information

NPI Number	:	1144784471
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON GOLTL ATC

Provider Business Mailing Address
First Line	:	5306 SILVER MILL DR
Second Line	:
City	:	COLUMBIA
State	:	MO
Zip	:	65202-6593
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2500 OLD HIGHWAY 63 S APT 7113
Second Line	:
City	:	COLUMBIA
State	:	MO
Zip	:	65201-2203
Country	:	US
Telephone Number	:	720-829-7575
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/31/2019
Last Update Date	:	06/28/2020

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