MEDICARE: MS. JANE M SHIMON ED.D., A.T.C.

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

General Provider Information

NPI Number	:	1154459014
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JANE M SHIMON ED.D., A.T.C.

Provider Business Mailing Address
First Line	:	3693 VINTAGE WAY
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83706-5448
Country	:	US
Telephone Number	:	208-426-1531
Fax Number	:

Provider Business Practice Location Address
First Line	:	1910 UNIVERSITY DR
Second Line	:	BOISE STATE UNIVERSITY
City	:	BOISE
State	:	ID
Zip	:	83725-0002
Country	:	US
Telephone Number	:	208-426-1531
Fax Number	:	208-426-1531

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

Provider Enumeration Date	:	03/01/2007
Last Update Date	:	07/08/2007

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