Healthcare Provider Details

I. General information

NPI: 1992125496
Provider Name (Legal Business Name): MARK MYERS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2014
Last Update Date: 09/05/2026
Certification Date: 09/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HP 260
MUNCIE IN
47306-0001
US

IV. Provider business mailing address

HP 260
MUNCIE IN
47306-0001
US

V. Phone/Fax

Practice location:
  • Phone: 285-765-1808
  • Fax:
Mailing address:
  • Phone: 765-285-1808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36003846A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: