Healthcare Provider Details

I. General information

NPI: 1033102645
Provider Name (Legal Business Name): ADAM ROBERT ANNACCONE LAT, ATC, PES, CES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 01/25/2020
Certification Date: 01/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13016 RIDGE SPRING DR
FRISCO TX
75035-1637
US

IV. Provider business mailing address

13016 RIDGE SPRING DR
FRISCO TX
75035-1637
US

V. Phone/Fax

Practice location:
  • Phone: 412-337-6032
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT6699
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: