Healthcare Provider Details

I. General information

NPI: 1417333774
Provider Name (Legal Business Name): MARK ANGELO COLAPIETRO ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2015
Last Update Date: 10/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

147 RECREATION HALL
UNIVERSITY PARK PA
16803-1716
US

IV. Provider business mailing address

730 TANAGER DR
STATE COLLEGE PA
16803-2502
US

V. Phone/Fax

Practice location:
  • Phone: 814-867-0476
  • Fax:
Mailing address:
  • Phone: 814-381-5093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT006443
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1417333774
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: