MEDICARE: DANIEL MUMMERT AT

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	0975	AZ

General Provider Information

NPI Number	:	1912274655
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIEL MUMMERT AT

Provider Business Mailing Address
First Line	:	4701 N CENTRAL AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85012-1723
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4701 N CENTRAL AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85012-1723
Country	:	US
Telephone Number	:	602-264-5291
Fax Number	:

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

Provider Enumeration Date	:	11/23/2011
Last Update Date	:	11/23/2011

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