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General NPI Number Information
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NPI Number | 1245792910
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Entity Type | Individual
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Provider Name | SAMANTHA PATRICIA BOURASSA ATC, LAT
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Gender | Female
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Dates
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Enumeration Date | 04/02/2019
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Last Update Date | 04/02/2019
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Provider Practice Location Address
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Address Line | 2832 E POLELINE AVE
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City | POST FALLS
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State | ID
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Zip | 83854
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Country | US
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Telephone | 208-773-0581
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Fax |
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Provider Business Mailing Address
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Address Line | 1852 DIPPER LOOP
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City | POST FALLS
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State | ID
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Zip | 83854-5647
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Country | US
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Telephone | 406-899-3757
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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 | AT-436
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License Number State | ID
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