Healthcare Provider Details

I. General information

NPI: 1922073527
Provider Name (Legal Business Name): STACEY R. KOFMAN ATC, PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 EMBARCADERO RD PALO ALTO HIGH SCHOOL
PALO ALTO CA
94301-2321
US

IV. Provider business mailing address

49 SHOWERS DR J324
MOUNTAIN VIEW CA
94040-1463
US

V. Phone/Fax

Practice location:
  • Phone: 650-329-3892
  • Fax: 650-566-0612
Mailing address:
  • Phone: 650-949-4561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: