Healthcare Provider Details

I. General information

NPI: 1891522108
Provider Name (Legal Business Name): ZANDER GABRIEL LICHOSIK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2024
Last Update Date: 06/16/2025
Certification Date: 06/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 BEAMER WAY
BLACKSBURG VA
24061-6267
US

IV. Provider business mailing address

320 CONTINENTAL CIR APT 201
CHRISTIANSBURG VA
24073-1209
US

V. Phone/Fax

Practice location:
  • Phone: 414-731-5342
  • Fax:
Mailing address:
  • Phone: 414-731-5342
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0126004290
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: