MEDICARE: KATHLEEN M TABER M.ED., ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	2185	MN

General Provider Information

NPI Number	:	1114267846
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN M TABER M.ED., ATC

Provider Business Mailing Address
First Line	:	600 HENNEPIN AVE
Second Line	:	SUITE 310
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55403-1816
Country	:	US
Telephone Number	:	612-750-3524
Fax Number	:

Provider Business Practice Location Address
First Line	:	600 HENNEPIN AVE
Second Line	:	SUITE 310
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55403-1816
Country	:	US
Telephone Number	:	612-750-3524
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/16/2013
Last Update Date	:	01/08/2021

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