=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336090109
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICHOLAS M ANNESI LAT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2026
-----------------------------------------------------
Last Update Date | 02/06/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16 DARTTS CROSS ROAD
-----------------------------------------------------
City | SPENCER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13760
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-621-7626
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 491 REYNOLDS RD
-----------------------------------------------------
City | JOHNSON CITY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13790-1369
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-729-0044
-----------------------------------------------------
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 | 005054
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------