MEDICARE: MR. TYLER JOSEPH ZAJAC LAT, 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	AT1125	KY

General Provider Information

NPI Number	:	1760878409
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TYLER JOSEPH ZAJAC LAT, ATC

Provider Business Mailing Address
First Line	:	9122 RAINBOW SPRINGS CT APT 3
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40241-2240
Country	:	US
Telephone Number	:	860-874-9541
Fax Number	:

Provider Business Practice Location Address
First Line	:	9122 RAINBOW SPRINGS CT APT 3
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40241-2240
Country	:	US
Telephone Number	:	860-874-9541
Fax Number	:

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

Provider Enumeration Date	:	04/09/2015
Last Update Date	:	04/09/2015

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