Healthcare Provider Details

I. General information

NPI: 1093257370
Provider Name (Legal Business Name): MICHAEL PLAISANCE ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2016
Last Update Date: 02/06/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1182 TROY SCHENECTADY RD
LATHAM NY
12110-1001
US

IV. Provider business mailing address

1540 TIBBITS AVE
TROY NY
12180-3632
US

V. Phone/Fax

Practice location:
  • Phone: 518-713-5400
  • Fax: 518-713-5401
Mailing address:
  • Phone: 802-733-8837
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number003863
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: