Provider Demographics
NPI:1790052058
Name:SHAKESPAERE, DUJUAN (MS,ATC,LAT)
Entity Type:Individual
Prefix:
First Name:DUJUAN
Middle Name:
Last Name:SHAKESPAERE
Suffix:
Gender:M
Credentials:MS,ATC,LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2568 E 160 S
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-6559
Mailing Address - Country:US
Mailing Address - Phone:818-300-5661
Mailing Address - Fax:
Practice Address - Street 1:652 S MEDICAL CTR DR
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-7017
Practice Address - Country:US
Practice Address - Phone:435-251-2286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-30
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7468860-48102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000002230OtherNATIONAL ATHLETIC TRAINERS' ASSOCIATION BOARD OF CERTIFICATION