Healthcare Provider Details

I. General information

NPI: 1639700057
Provider Name (Legal Business Name): LACY L GUNN MS, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2020
Last Update Date: 02/04/2020
Certification Date: 02/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SUNY CORTLAND
CORTLAND NY
13045
US

IV. Provider business mailing address

4 AUSTIN RD
TULLY NY
13159-2409
US

V. Phone/Fax

Practice location:
  • Phone: 607-753-4787
  • Fax: 607-753-5929
Mailing address:
  • Phone: 607-753-4787
  • Fax: 607-753-5959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number002260-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: