Healthcare Provider Details

I. General information

NPI: 1265052740
Provider Name (Legal Business Name): MAX ANGLEA ZAWEL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2020
Last Update Date: 04/24/2020
Certification Date: 04/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 RECREATION BLDG
UNIVERSITY PARK PA
16802-5700
US

IV. Provider business mailing address

140 RECREATION BLDG
UNIVERSITY PARK PA
16802-5700
US

V. Phone/Fax

Practice location:
  • Phone: 857-265-8333
  • Fax:
Mailing address:
  • Phone: 857-265-8333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberS87725500
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberS87725500
License Number StateMA

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: