MEDICARE: MISS COLLEEN AARON SHOTWELL MS, 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	RT002404A	PA

General Provider Information

NPI Number	:	1841328937
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS COLLEEN AARON SHOTWELL MS, ATC

Provider Business Mailing Address
First Line	:	2 RAILROAD ST
Second Line	:
City	:	AVOCA
State	:	PA
Zip	:	18641-1044
Country	:	US
Telephone Number	:	570-237-6130
Fax Number	:	570-422-3665

Provider Business Practice Location Address
First Line	:	200 PROSPECT ST
Second Line	:	KOEHLER FIELDHOUSE
City	:	EAST STROUDSBURG
State	:	PA
Zip	:	18301-2956
Country	:	US
Telephone Number	:	570-422-3165
Fax Number	:	570-422-3665

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

Provider Enumeration Date	:	03/01/2007
Last Update Date	:	07/08/2007

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