Provider Demographics
NPI:1124459425
Name:VANG, SHATT (ATC)
Entity type:Individual
Prefix:
First Name:SHATT
Middle Name:
Last Name:VANG
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 ALLEGHANY ST
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-3734
Mailing Address - Country:US
Mailing Address - Phone:704-564-6563
Mailing Address - Fax:
Practice Address - Street 1:4400 GOLF ACRES DR
Practice Address - Street 2:BUILDING J, SUITE D
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208-5990
Practice Address - Country:US
Practice Address - Phone:704-614-4594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-11
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC22802255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer