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General NPI Number Information
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NPI Number | 1487050902
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Entity Type | Individual
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Provider Name | JUSTIN HENRY CORCORAN MSA, ATC, LAT
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Gender | Male
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Dates
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Enumeration Date | 11/11/2014
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Last Update Date | 11/11/2014
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Provider Practice Location Address
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Address Line | 68 RIVER RD
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City | SUMMIT
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State | NJ
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Zip | 07901-1450
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Country | US
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Telephone | 201-277-0800
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Fax |
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Provider Business Mailing Address
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Address Line | 10 LAYTON RD APT 57
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City | WANTAGE
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State | NJ
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Zip | 07461-1805
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Country | US
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Telephone | 973-459-2319
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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 | 002266-1
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License Number State | NY
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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 | 25MT00178900
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License Number State | NJ
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