Provider Demographics
NPI:1174126890
Name:HIPP, TREVOR SHANE (RDN)
Entity type:Individual
Prefix:
First Name:TREVOR
Middle Name:SHANE
Last Name:HIPP
Suffix:
Gender:M
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 FRANCIS DR
Mailing Address - Street 2:
Mailing Address - City:NARROWSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:12764-5728
Mailing Address - Country:US
Mailing Address - Phone:928-920-6351
Mailing Address - Fax:
Practice Address - Street 1:641 OLD ROUTE 17
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:NY
Practice Address - Zip Code:12701-7014
Practice Address - Country:US
Practice Address - Phone:928-920-6351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY86041583133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered