Healthcare Provider Details

I. General information

NPI: 1417374026
Provider Name (Legal Business Name): PRESTON JAMES ANDERON MS, LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2014
Last Update Date: 03/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 THOMAS JOHNSON DR SUITE 180
FREDERICK MD
21702-4502
US

IV. Provider business mailing address

141 THOMAS JOHNSON DR SUITE 180
FREDERICK MD
21702-4502
US

V. Phone/Fax

Practice location:
  • Phone: 301-620-7478
  • Fax: 301-620-7479
Mailing address:
  • Phone: 301-620-7478
  • Fax: 301-620-7479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberA0000519
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT005168
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: