Provider Demographics
NPI:1073021291
Name:SHAMBLIN, TREVOR ALLAN
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:ALLAN
Last Name:SHAMBLIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4301 MCCORKLE AVE SE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-2503
Mailing Address - Country:US
Mailing Address - Phone:304-720-9185
Mailing Address - Fax:
Practice Address - Street 1:4301 MCCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-2503
Practice Address - Country:US
Practice Address - Phone:304-720-9185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-22
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist