Healthcare Provider Details

I. General information

NPI: 1194459156
Provider Name (Legal Business Name): ANAIS MOTON LAT, ATC, MBL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2022
Last Update Date: 07/14/2022
Certification Date: 07/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 CAMPUS RD
ANNANDALE ON HUDSON NY
12504-9800
US

IV. Provider business mailing address

9 HAWTHORNE AVE
TROY NY
12180-4714
US

V. Phone/Fax

Practice location:
  • Phone: 845-758-7694
  • Fax:
Mailing address:
  • Phone: 224-656-4097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number003609
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: