MEDICARE: SARAH MARLENE SHADE ATC, NREMT

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	207PE0004X	Emergency Medical Services (Emergency Medicine) Physician	2023038475	UT
2	2255A2300X	Athletic Trainer	12945874-4810	UT
3	2255A2300X	Athletic Trainer	004879	NY
4	2255A2300X	Athletic Trainer	AT006365	OH

General Provider Information

NPI Number	:	1467081588
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SARAH MARLENE SHADE ATC, NREMT

Provider Business Mailing Address
First Line	:	2940 S 2300 E
Second Line	:
City	:	MILLCREEK
State	:	UT
Zip	:	84109-1924
Country	:	US
Telephone Number	:	614-600-4392
Fax Number	:

Provider Business Practice Location Address
First Line	:	2940 S 2300 E
Second Line	:
City	:	MILLCREEK
State	:	UT
Zip	:	84109-1924
Country	:	US
Telephone Number	:	614-600-4392
Fax Number	:

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

Provider Enumeration Date	:	04/02/2020
Last Update Date	:	03/24/2025

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