Provider Demographics
NPI:1497124143
Name:SHIVOCK, PAULA (LAT ATC)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:
Last Name:SHIVOCK
Suffix:
Gender:F
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 1:652 S MEDICAL CENTER DR STE 120
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-7077
Mailing Address - Country:US
Mailing Address - Phone:570-878-9818
Mailing Address - Fax:
Practice Address - Street 1:440 N 5TH ST
Practice Address - Street 2:
Practice Address - City:STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18360-2439
Practice Address - Country:US
Practice Address - Phone:570-878-9818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-23
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
UT12014120-48102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000026336OtherATHLETIC TRAINER CERTIFIED BOC
UT12014120-4810OtherLICENSED ATHLETIC TRAINER