Healthcare Provider Details

I. General information

NPI: 1871138784
Provider Name (Legal Business Name): AARON VANDYNE LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2019
Last Update Date: 12/29/2025
Certification Date: 09/24/2020
Deactivation Date: 09/24/2020
Reactivation Date: 12/29/2025

III. Provider practice location address

722 E SACK DR
PHOENIX AZ
85024-8232
US

IV. Provider business mailing address

722 E SACK DR
PHOENIX AZ
85024-8232
US

V. Phone/Fax

Practice location:
  • Phone: 928-533-5309
  • Fax:
Mailing address:
  • Phone: 928-533-5309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberATR-009236
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: