Provider Demographics
NPI:1710718291
Name:SHAMPO, MICHAEL RICHARD (LAT, ATC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RICHARD
Last Name:SHAMPO
Suffix:
Gender:M
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 1:702 MICHAELIS ST
Mailing Address - Street 2:
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143-1041
Mailing Address - Country:US
Mailing Address - Phone:906-748-4603
Mailing Address - Fax:
Practice Address - Street 1:2135 PIERCE AVE
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-3947
Practice Address - Country:US
Practice Address - Phone:715-735-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-08
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1107-392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer