Provider Demographics
NPI:1063956647
Name:SHIFFLETT, JOHN (LAT, ATC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:SHIFFLETT
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6913
Mailing Address - Street 2:
Mailing Address - City:RADFORD
Mailing Address - State:VA
Mailing Address - Zip Code:24142-6913
Mailing Address - Country:US
Mailing Address - Phone:540-831-6128
Mailing Address - Fax:
Practice Address - Street 1:101 UNIVERSITY DRIVE
Practice Address - Street 2:
Practice Address - City:RADFORD
Practice Address - State:VA
Practice Address - Zip Code:24141-6913
Practice Address - Country:US
Practice Address - Phone:540-831-6128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-15
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260012712255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer