=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508227984
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PATRICK PATTI MLS, LAT, ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2016
-----------------------------------------------------
Last Update Date | 12/05/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 NICOLLS RD
-----------------------------------------------------
City | STONY BROOK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11794-2202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-632-7583
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 246 DAVIDSON AVE
-----------------------------------------------------
City | RAMSEY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07446-1004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-921-7757
-----------------------------------------------------
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 | 1522
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 003972
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------