Healthcare Provider Details

I. General information

NPI: 1093778383
Provider Name (Legal Business Name): GERARD M. GINGRAS ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2006
Last Update Date: 04/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 UPPER COLLEGE DR ALFRED STATE COLLEGE
ALFRED NY
14802-1153
US

IV. Provider business mailing address

10 UPPER COLLEGE DR ALFRED STATE COLLEGE
ALFRED NY
14802-1153
US

V. Phone/Fax

Practice location:
  • Phone: 607-587-4388
  • Fax:
Mailing address:
  • Phone: 607-587-4388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number001155-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: