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General NPI Number Information
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NPI Number | 1710596093
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Entity Type | Individual
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Provider Name | TREVOR LANE KISTLER LAT, ATC
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Gender | Male
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Dates
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Enumeration Date | 07/23/2020
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Last Update Date | 07/23/2020
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Provider Practice Location Address
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Address Line | 600 TX-349
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City | IRAAN
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State | TX
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Zip | 79744
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Country | US
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Telephone | 432-639-2575
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 653
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City | IRAAN
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State | TX
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Zip | 79744-0653
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Country | US
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Telephone | 817-721-2048
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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 | AT6983
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License Number State | TX
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