MEDICARE: MICHAELA HOFFMAN LAT, ATC, CSCS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1043604820
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAELA HOFFMAN LAT, ATC, CSCS

Provider Business Mailing Address
First Line	:	10035 NORTHBROOK VALLEY DR APT 8
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-2380
Country	:	US
Telephone Number	:	260-610-3454
Fax Number	:

Provider Business Practice Location Address
First Line	:	3701 CARROLL RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46818-9528
Country	:	US
Telephone Number	:	260-637-3161
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/19/2015
Last Update Date	:	09/08/2019

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