Healthcare Provider Details

I. General information

NPI: 1649669359
Provider Name (Legal Business Name): DAVID JAKE MALDONADO ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2015
Last Update Date: 04/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 VERDE RIDGE ST APT C
LOS ALAMOS NM
87544-3243
US

IV. Provider business mailing address

30 VERDE RIDGE ST APT C
LOS ALAMOS NM
87544-3243
US

V. Phone/Fax

Practice location:
  • Phone: 505-515-9816
  • Fax:
Mailing address:
  • Phone: 505-515-9816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: