Healthcare Provider Details

I. General information

NPI: 1316361207
Provider Name (Legal Business Name): JOSEPH ZIDAR ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2014
Last Update Date: 02/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 COLLEGE AVE
GREENVILLE PA
16125-2186
US

IV. Provider business mailing address

75 COLLEGE AVE
GREENVILLE PA
16125-2186
US

V. Phone/Fax

Practice location:
  • Phone: 724-589-2143
  • Fax: 724-589-2880
Mailing address:
  • Phone: 724-589-2143
  • Fax: 724-589-2880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT005329
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: