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General NPI Number Information
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NPI Number | 1073973855
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Entity Type | Individual
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Provider Name | MR. DANIEL TODD WASYLK
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Gender | Male
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Dates
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Enumeration Date | 03/07/2016
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Last Update Date | 03/07/2016
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Provider Practice Location Address
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Address Line | 11130 PARKVIEW CIRCLE DR
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City | FORT WAYNE
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State | IN
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Zip | 46845-1735
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Country | US
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Telephone | 260-710-1908
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Fax |
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Provider Business Mailing Address
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Address Line | 11111 HOAGLAND RD
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City | HOAGLAND
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State | IN
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Zip | 46745-9582
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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 | 36001783A
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License Number State | IN
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