Healthcare Provider Details

I. General information

NPI: 1215998265
Provider Name (Legal Business Name): DAVID N. SUPRAK MS, ATC, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2250 PATTERSON ST APT. 256
EUGENE OR
97405-2984
US

IV. Provider business mailing address

2250 PATTERSON ST APT. 256
EUGENE OR
97405-2993
US

V. Phone/Fax

Practice location:
  • Phone: 541-346-7318
  • Fax:
Mailing address:
  • Phone: 541-346-7318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: