MEDICARE: MR. JOHN JOSHUA SAND 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	1519	MN

General Provider Information

NPI Number	:	1609887686
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN JOSHUA SAND ATC

Provider Business Mailing Address
First Line	:	504 HAYES DR
Second Line	:
City	:	NORTHFIELD
State	:	MN
Zip	:	55057-3539
Country	:	US
Telephone Number	:	651-307-4963
Fax Number	:

Provider Business Practice Location Address
First Line	:	710 DIVISION ST S
Second Line	:
City	:	NORTHFIELD
State	:	MN
Zip	:	55057-2468
Country	:	US
Telephone Number	:	507-646-6854
Fax Number	:

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

Provider Enumeration Date	:	08/11/2006
Last Update Date	:	07/08/2007

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