Healthcare Provider Details

I. General information

NPI: 1508478421
Provider Name (Legal Business Name): TIMOTHY JOHN FUGATE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2020
Last Update Date: 08/21/2020
Certification Date: 08/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 PETERS RD STE 200
LITITZ PA
17543-7685
US

IV. Provider business mailing address

113 COUNTRY SIDE LN
LEOLA PA
17540-1647
US

V. Phone/Fax

Practice location:
  • Phone: 717-627-7675
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRTO000456
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: