Healthcare Provider Details

I. General information

NPI: 1649643289
Provider Name (Legal Business Name): STEVEN PAYSON ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2015
Last Update Date: 11/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 COLLEGE BLVD
ONTARIO OR
97914-3423
US

IV. Provider business mailing address

4275 S TRAILRIDGE AVE
BOISE ID
83716-6633
US

V. Phone/Fax

Practice location:
  • Phone: 541-881-5882
  • Fax:
Mailing address:
  • Phone: 208-761-5918
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT-545
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: