MEDICARE: MR. ANTHONY DUANE FITZPATRICK 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	AT035	ID

General Provider Information

NPI Number	:	1780613125
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ANTHONY DUANE FITZPATRICK LAT, ATC

Provider Business Mailing Address
First Line	:	3915 E WORMWOOD CT
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83716-6938
Country	:	US
Telephone Number	:	208-331-5077
Fax Number	:

Provider Business Practice Location Address
First Line	:	701 E BOISE AVE
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83706-5119
Country	:	US
Telephone Number	:	208-854-6230
Fax Number	:	208-854-6232

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

Provider Enumeration Date	:	06/30/2006
Last Update Date	:	07/08/2007

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