Healthcare Provider Details

I. General information

NPI: 1144202201
Provider Name (Legal Business Name): ERIN SIGURD STAVE A.T.,C
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 E 2ND ST DULUTH CLINIC SPORTS MEDICINE
DULUTH MN
55805-1906
US

IV. Provider business mailing address

6238 FOREST DR
DULUTH MN
55803-9428
US

V. Phone/Fax

Practice location:
  • Phone: 218-590-1059
  • Fax: 218-786-5435
Mailing address:
  • Phone: 218-786-0475
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1856
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: