Healthcare Provider Details

I. General information

NPI: 1659007979
Provider Name (Legal Business Name): THOMAS WILLIAM FLYNN JR. ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2022
Last Update Date: 07/28/2022
Certification Date: 07/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

645 STEWART AVE
GARDEN CITY NY
11530-4769
US

IV. Provider business mailing address

4161 LUDWIG LN
BETHPAGE NY
11714-6222
US

V. Phone/Fax

Practice location:
  • Phone: 609-970-4654
  • Fax:
Mailing address:
  • Phone: 609-970-4654
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number25MT00223700
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number003833
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: