=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306206396
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TARA CATHERINE MARTIN MS, ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2016
-----------------------------------------------------
Last Update Date | 03/03/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 639 HOWARD RD
-----------------------------------------------------
City | WEST POINT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10996-1510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-938-2297
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12A LIBERTY ST
-----------------------------------------------------
City | HIGHLAND FALLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10928-1918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 002863
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------