Healthcare Provider Details

I. General information

NPI: 1891110425
Provider Name (Legal Business Name): MIZUE IWAMOTO MS, ATC, CSCS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2014
Last Update Date: 01/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 8TH ST
TROY NY
12180-3522
US

IV. Provider business mailing address

110 8TH ST
TROY NY
12180-3522
US

V. Phone/Fax

Practice location:
  • Phone: 518-276-2884
  • Fax:
Mailing address:
  • Phone: 518-276-2884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number002095
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: