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General NPI Number Information
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NPI Number | 1770545113
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Entity Type | Individual
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Provider Name | GUSTAVE WALTER YOUNGER III ATC, LAT
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Gender | Male
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Dates
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Enumeration Date | 04/03/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | STEPHEN F. AUSTIN STATE UNIVERSITY HOMER BRYCE STADIUM FIELD HOUSE
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City | NACOGDOCHES
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State | TX
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Zip | 75962-0001
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Country | US
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Telephone | 936-468-4550
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Fax | 936-468-4052
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Provider Business Mailing Address
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Address Line | STEPHEN F. AUSTIN STATE UNIVERSITY P.O. BOX 13010 SFA STATION
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City | NACOGDOCHES
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State | TX
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Zip | 75962-0001
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Country | US
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Telephone | 936-468-4550
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Fax | 936-468-4052
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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 | AT3062
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License Number State | TX
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