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General NPI Number Information
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NPI Number | 1548863186
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Entity Type | Individual
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Provider Name | JASON MATTHEW MACCANNON ATC, LAT
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Gender | Male
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Dates
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Enumeration Date | 11/17/2020
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Last Update Date | 11/17/2020
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Provider Practice Location Address
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Address Line | COLLEGE BACKBONE RD
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City | PRINCESS ANNE
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State | MD
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Zip | 21853
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Country | US
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Telephone | 410-651-6510
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Fax |
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Provider Business Mailing Address
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Address Line | 1324 ASPEN DR
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City | SALISBURY
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State | MD
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Zip | 21804-2065
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Country | US
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Telephone |
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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 | A0001341
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License Number State | MD
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