Healthcare Provider Details

I. General information

NPI: 1467427104
Provider Name (Legal Business Name): SHINICHIRO SUGIURA PH.D., LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 08/31/2020
Certification Date: 08/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 REC HALL
UNIVERSITY PARK PA
16803-1680
US

IV. Provider business mailing address

THE PENNSYLVANIA STATE UNIVERSITY 146 REC HALL
UNIVERSITY PARK PA
16803-1590
US

V. Phone/Fax

Practice location:
  • Phone: 814-865-8387
  • Fax:
Mailing address:
  • Phone: 814-865-8387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36001406A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT007420
License Number StatePA

VII. Legacy identifiers

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

# 1
IdentifierRT007420
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerATHLETIC TRAINER
# 2
Identifier36001406A
Identifier TypeOTHER
Identifier StateIN
Identifier IssuerATHLETIC TRAINER

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: