Healthcare Provider Details

I. General information

NPI: 1023199619
Provider Name (Legal Business Name): MARTIN ANDREW DONAHUE PH.D., ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 ELECTRIC ST
CLARKS SUMMIT PA
18411-1933
US

IV. Provider business mailing address

2300 ADAMS AVE DEPARTMENT OF HEALTH AND PHYSICAL EDUCATION
SCRANTON PA
18509-1514
US

V. Phone/Fax

Practice location:
  • Phone: 570-586-0951
  • Fax:
Mailing address:
  • Phone: 570-348-6259
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT003664
License Number StatePA

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: