MEDICARE: SERENA ANITA SHAH ATC

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	AL6525	FL

General Provider Information

NPI Number	:	1568935336
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SERENA ANITA SHAH ATC

Provider Business Mailing Address
First Line	:	4440 OLD TAMPA HWY
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33811-1135
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4440 OLD TAMPA HWY
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33811-1135
Country	:	US
Telephone Number	:	999-999-9999
Fax Number	:

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

Provider Enumeration Date	:	01/04/2019
Last Update Date	:	06/27/2024

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