Healthcare Provider Details

I. General information

NPI: 1184240889
Provider Name (Legal Business Name): DEBRA IWANOW ATC, CSCS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2020
Last Update Date: 06/18/2020
Certification Date: 06/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 RIVERSIDE DR
BINGHAMTON NY
13905-4246
US

IV. Provider business mailing address

29 DELVIEW TER
DELHI NY
13753-1056
US

V. Phone/Fax

Practice location:
  • Phone: 607-592-1225
  • Fax:
Mailing address:
  • Phone: 607-592-1225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL3019
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number001234
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: