MEDICARE: MS. MARY AGNES PIECHOTA A.T.,C

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	RT000295A	PA

General Provider Information

NPI Number	:	1487681029
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY AGNES PIECHOTA A.T.,C

Provider Business Mailing Address
First Line	:	RR 3 BOX 3196
Second Line	:	BLUE RIDGE ROAD
City	:	SAYLORSBURG
State	:	PA
Zip	:	18353-9631
Country	:	US
Telephone Number	:	610-381-7246
Fax Number	:	570-839-0974

Provider Business Practice Location Address
First Line	:	POCONO MOUNTAIN WEST HIGHSCHOOL
Second Line	:	HC 89 BOX 2002 ROUTE 940
City	:	POCONO SUMMITT, PA.
State	:	PA
Zip	:	18346
Country	:	US
Telephone Number	:	570-839-7121
Fax Number	:	570-839-0974

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

Provider Enumeration Date	:	06/27/2006
Last Update Date	:	07/08/2007

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