Healthcare Provider Details

I. General information

NPI: 1144772021
Provider Name (Legal Business Name): MEGAN BOBISH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2016
Last Update Date: 10/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

624 CARLETON AVE
HAZLETON PA
18201-7457
US

IV. Provider business mailing address

624 CARLETON AVE
HAZLETON PA
18201-7457
US

V. Phone/Fax

Practice location:
  • Phone: 570-582-7339
  • Fax:
Mailing address:
  • Phone: 570-582-7339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: