Healthcare Provider Details

I. General information

NPI: 1255805529
Provider Name (Legal Business Name): ZACHARY EDWARDS ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2019
Last Update Date: 01/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

289 W MAIN ST
HANCOCK MD
21750-1342
US

IV. Provider business mailing address

3621 OAKLEY LN
GREENCASTLE PA
17225-8747
US

V. Phone/Fax

Practice location:
  • Phone: 818-630-1766
  • Fax:
Mailing address:
  • Phone: 814-279-4049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT005774
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberA0000652
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: