Healthcare Provider Details

I. General information

NPI: 1578483285
Provider Name (Legal Business Name): FISNIK ISUFI LAT, ATC, MBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 RIVER RD
TEANECK NJ
07666-1938
US

IV. Provider business mailing address

633 PALISADE AVE APT 2C
CLIFFSIDE PARK NJ
07010-3078
US

V. Phone/Fax

Practice location:
  • Phone: 877-338-8002
  • Fax:
Mailing address:
  • Phone: 551-574-7559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number25MT00347900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: