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NPI Code Detail

MEDICARE: SARAH SHUTE ATC, LAT

MEDICARE: SARAH SHUTE ATC, LAT
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
12255A2300XAthletic Trainer0869AZ

General Provider Information

NPI Number : 1396013371
Entity Type Code : Individual
Provider Name (Legal Business Name) : SARAH SHUTE ATC, LAT
Provider Business Mailing Address
First Line : PO BOX 15400
Second Line :
City : FLAGSTAFF
State : AZ
Zip : 86011-0556
Country : US
Telephone Number : 928-523-4152
Fax Number : 928-523-8464
Provider Business Practice Location Address
First Line : 1701 N SAN FRANCISCO ST
Second Line :
City : FLAGSTAFF
State : AZ
Zip : 86001-1348
Country : US
Telephone Number : 928-523-4152
Fax Number : 928-523-8464
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/06/2011
Last Update Date : 12/06/2011

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