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General NPI Number Information
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NPI Number | 1427861517
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Entity Type | Individual
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Provider Name | MARIANO GONZALEZ JR. ATC
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Gender | Male
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Dates
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Enumeration Date | 01/31/2025
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Last Update Date | 01/31/2025
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Provider Practice Location Address
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Address Line | 380 OLD TOWN RD
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City | EAST SETAUKET
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State | NY
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Zip | 11733-3482
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Country | US
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Telephone | 631-730-4980
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Fax |
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Provider Business Mailing Address
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Address Line | 100 SUFFOLK AVE
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City | STONY BROOK
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State | NY
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Zip | 11790-1821
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Country | US
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Telephone | 631-730-4000
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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 | 002969
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License Number State | NY
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