=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235895400
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT JOHN JONES M.ED. , ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/12/2021
-----------------------------------------------------
Last Update Date | 11/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 409 AVIATION RD
-----------------------------------------------------
City | QUEENSBURY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12804-2913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-824-4600
-----------------------------------------------------
Fax | 518-824-4682
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 409 AVIATION RD
-----------------------------------------------------
City | QUEENSBURY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12804-2913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-824-4600
-----------------------------------------------------
Fax | 518-824-4682
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 1112696
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------