Healthcare Provider Details

I. General information

NPI: 1053321216
Provider Name (Legal Business Name): SEAN MICHAEL KUPIEC MA, ATC, PES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

GILLETTE STADIUM ONE PATRIOT PLACE
FOXBORO MA
02035-1388
US

IV. Provider business mailing address

6866 TRENTON RD
BARNEVELD NY
13304-2607
US

V. Phone/Fax

Practice location:
  • Phone: 508-384-9113
  • Fax:
Mailing address:
  • Phone: 315-292-0222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1054
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: