Provider Demographics
NPI:1427663251
Name:SHAUT, DEVON MICHELLE
Entity type:Individual
Prefix:
First Name:DEVON
Middle Name:MICHELLE
Last Name:SHAUT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 FREDERICA ST
Mailing Address - Street 2:ATHLETIC TRAINING ROOM
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42301
Mailing Address - Country:US
Mailing Address - Phone:651-270-3801
Mailing Address - Fax:
Practice Address - Street 1:3000 FREDERICA ST
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-4230
Practice Address - Country:US
Practice Address - Phone:651-270-3801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-09
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY20000397742083S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY2000039774OtherBOARD OF CERTIFICATION