MEDICARE: SHANNON KANE MAT

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	:	1336528736
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON KANE MAT

Provider Business Mailing Address
First Line	:	374 S GRAND BLVD
Second Line	:	BOX 58
City	:	SAINT LOUIS
State	:	MO
Zip	:	63103-2415
Country	:	US
Telephone Number	:	850-454-6487
Fax Number	:

Provider Business Practice Location Address
First Line	:	374 S GRAND BLVD
Second Line	:	BOX 58
City	:	SAINT LOUIS
State	:	MO
Zip	:	63103-2415
Country	:	US
Telephone Number	:	850-454-6487
Fax Number	:

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

Provider Enumeration Date	:	05/19/2015
Last Update Date	:	05/19/2015

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Directions to “ SHANNON KANE MAT” Practice Location

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