Healthcare Provider Details

I. General information

NPI: 1942264528
Provider Name (Legal Business Name): ERIC WILLIAM GAHAN ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2006
Last Update Date: 01/07/2022
Certification Date: 01/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 ROYAL AMETHYST WAY
LAS VEGAS NV
89178-2432
US

IV. Provider business mailing address

901 ROYAL AMETHYST WAY
LAS VEGAS NV
89178-2432
US

V. Phone/Fax

Practice location:
  • Phone: 617-694-3813
  • Fax:
Mailing address:
  • Phone: 617-694-3813
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1945
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: