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General NPI Number Information
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NPI Number | 1366056301
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Entity Type | Individual
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Provider Name | DEMETRI EUGENE PROBST
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Gender | Male
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Dates
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Enumeration Date | 09/08/2020
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Last Update Date | 04/28/2025
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Provider Practice Location Address
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Address Line | 248 SUSQUEHANNA AVE
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City | RENOVO
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State | PA
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Zip | 17764-1523
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Country | US
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Telephone | 570-786-7751
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Fax |
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Provider Business Mailing Address
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Address Line | 248 SUSQUEHANNA AVE
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City | RENOVO
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State | PA
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Zip | 17764-1523
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Country | US
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Telephone | 570-786-7751
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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 | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | RT007867
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License Number State | PA
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