Healthcare Provider Details

I. General information

NPI: 1992835623
Provider Name (Legal Business Name): BRANDYN SHANE CHARLTON MA, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 COLLEGE PLACE LYCOMING COLLEGE
WILLIAMSPORT PA
17701-5192
US

IV. Provider business mailing address

3 ASHLEE LN
DANVILLE PA
17821-9774
US

V. Phone/Fax

Practice location:
  • Phone: 570-321-4271
  • Fax: 570-321-4158
Mailing address:
  • Phone: 570-275-6735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT001818A
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: