MEDICARE: DEVON MICHELLE SHAUT

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	2083S0010X	Sports Medicine (Preventive Medicine) Physician	2000039774	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2000039774	OTHER	KY	BOARD OF CERTIFICATION

General Provider Information

NPI Number	:	1427663251
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEVON MICHELLE SHAUT

Provider Business Mailing Address
First Line	:	3000 FREDERICA ST
Second Line	:	ATHLETIC TRAINING ROOM
City	:	OWENSBORO
State	:	KY
Zip	:	42301
Country	:	US
Telephone Number	:	651-270-3801
Fax Number	:

Provider Business Practice Location Address
First Line	:	3000 FREDERICA ST
Second Line	:
City	:	OWENSBORO
State	:	KY
Zip	:	42301-4230
Country	:	US
Telephone Number	:	651-270-3801
Fax Number	:

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

Provider Enumeration Date	:	09/09/2020
Last Update Date	:	09/09/2020

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Directions to “ DEVON MICHELLE SHAUT ” Practice Location

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