Healthcare Provider Details

I. General information

NPI: 1467561274
Provider Name (Legal Business Name): PATRICIA LYNN GUNDLACH M.S., A.T.C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5030 STATE HIGHWAY 30
AMSTERDAM NY
12010-7534
US

IV. Provider business mailing address

44 MARION BLVD
SCOTIA NY
12302-2602
US

V. Phone/Fax

Practice location:
  • Phone: 518-841-3406
  • Fax:
Mailing address:
  • Phone: 518-393-3334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number000358-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: