Healthcare Provider Details

I. General information

NPI: 1831741339
Provider Name (Legal Business Name): ANDRE MICHAEL VENNER MS, LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2019
Last Update Date: 07/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 W ROE BLVD
PATCHOGUE NY
11772-2325
US

IV. Provider business mailing address

145 DOGWOOD DR
WADING RIVER NY
11792-1605
US

V. Phone/Fax

Practice location:
  • Phone: 914-906-3735
  • Fax:
Mailing address:
  • Phone: 914-906-3735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number002919-1
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: