Healthcare Provider Details

I. General information

NPI: 1497152581
Provider Name (Legal Business Name): MARSHALL KRAKER ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2014
Last Update Date: 12/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 HOSPITAL LOOP
CRAIG CO
81625-8750
US

IV. Provider business mailing address

3647 JUNIPER PL APT. 12
CRAIG CO
81625-3619
US

V. Phone/Fax

Practice location:
  • Phone: 970-824-9911
  • Fax:
Mailing address:
  • Phone: 970-846-8918
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT.0001367
License Number StateCO

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: