Healthcare Provider Details

I. General information

NPI: 1477356095
Provider Name (Legal Business Name): IAN ALEXANDER JEFFER ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2025
Last Update Date: 03/29/2025
Certification Date: 03/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10045 E MADERO AVE
MESA AZ
85209-1399
US

IV. Provider business mailing address

1725 S CORONADO RD APT 3101
GILBERT AZ
85295-0249
US

V. Phone/Fax

Practice location:
  • Phone: 480-415-4120
  • Fax:
Mailing address:
  • Phone: 480-415-4120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberATR-009548
License Number StateAZ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: