Healthcare Provider Details

I. General information

NPI: 1619485000
Provider Name (Legal Business Name): NATHAN RYAN DIFFIN ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2018
Last Update Date: 04/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 WASHINGTON ST
AYER MA
01432-1245
US

IV. Provider business mailing address

141 WASHINGTON ST
AYER MA
01432-1245
US

V. Phone/Fax

Practice location:
  • Phone: 978-772-8600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

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: