Healthcare Provider Details

I. General information

NPI: 1760474209
Provider Name (Legal Business Name): ROBIN MICHELLE MARICHAK ATHLETIC TRAINER
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/19/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E MOUNTAIN BLVD
WILKES BARRE PA
18711-0027
US

IV. Provider business mailing address

56 HILLSIDE ST
WILKES BARRE PA
18702-6406
US

V. Phone/Fax

Practice location:
  • Phone: 570-820-6086
  • Fax:
Mailing address:
  • Phone: 570-826-0922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberRT002124A
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: