MEDICARE: MAEGAN MARIE MATHISEN ATCLAT

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	AL2281	FL

General Provider Information

NPI Number	:	1689884231
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAEGAN MARIE MATHISEN ATCLAT

Provider Business Mailing Address
First Line	:	165 OCEAN HOLLOW LN
Second Line	:
City	:	ST AUGUSTINE
State	:	FL
Zip	:	32084-1779
Country	:	US
Telephone Number	:	561-504-1862
Fax Number	:

Provider Business Practice Location Address
First Line	:	9191 RG SKINNER PKWY
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256
Country	:	US
Telephone Number	:	904-854-7474
Fax Number	:

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

Provider Enumeration Date	:	05/23/2007
Last Update Date	:	07/08/2007

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