MEDICARE: THOMAS SHELTON LAT, ATC, RN

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	163W00000X	Registered Nurse	R103177	AR
2	2255A2300X	Athletic Trainer	AT 277	AR
3	363LF0000X	Family Nurse Practitioner	125715	AR
4	363LF0000X	Family Nurse Practitioner	26521	SC

General Provider Information

NPI Number	:	1770575557
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOMAS SHELTON LAT, ATC, RN

Provider Business Mailing Address
First Line	:	PO BOX 3239
Second Line	:
City	:	FLORENCE
State	:	SC
Zip	:	29502-3239
Country	:	US
Telephone Number	:	843-487-1588
Fax Number	:	843-487-1590

Provider Business Practice Location Address
First Line	:	705 N 8TH AVE STE 1B
Second Line	:
City	:	DILLON
State	:	SC
Zip	:	29536-2549
Country	:	US
Telephone Number	:	843-487-1588
Fax Number	:	843-487-1590

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

Provider Enumeration Date	:	08/18/2005
Last Update Date	:	09/26/2022

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