Provider Demographics
NPI:1467081588
Name:SHADE, SARAH MARLENE (ATC, EMT)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:MARLENE
Last Name:SHADE
Suffix:
Gender:F
Credentials:ATC, EMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:694 E UNION GARDEN CT
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-2400
Mailing Address - Country:US
Mailing Address - Phone:614-600-4392
Mailing Address - Fax:
Practice Address - Street 1:694 E UNION GARDEN CT
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-2400
Practice Address - Country:US
Practice Address - Phone:614-600-4392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-02
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2023038475207PE0004X
2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services