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General NPI Number Information
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NPI Number | 1073932430
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Entity Type | Individual
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Provider Name | JON JUNGWIRTH ATC
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Gender | Male
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Dates
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Enumeration Date | 04/14/2014
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Last Update Date | 04/14/2014
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Provider Practice Location Address
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Address Line | W8824 PETERSON DR
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City | IRON MOUNTAIN
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State | MI
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Zip | 49801-9504
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Country | US
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Telephone | 906-396-2143
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Fax |
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Provider Business Mailing Address
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Address Line | W8824 PETERSON DR
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City | IRON MOUNTAIN
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State | MI
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Zip | 49801-9504
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 2601000946
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License Number State | MI
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