Healthcare Provider Details

I. General information

NPI: 1013480714
Provider Name (Legal Business Name): ANDREW TRAUT ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2019
Last Update Date: 01/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

OREGON STATE FORCE LAB 2200 NE NEFF RD SUITE 202
BEND OR
97701
US

IV. Provider business mailing address

140 SE MAYBERRY AVE
CORVALLIS OR
97333-1737
US

V. Phone/Fax

Practice location:
  • Phone: 404-401-1596
  • Fax:
Mailing address:
  • Phone: 404-401-1596
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT-10135659
License Number StateOR

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: