MEDICARE: DUANE KORTHUIS ATC

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	2255A2300X	Athletic Trainer	A1 60045559

General Provider Information

NPI Number	:	1295151900
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DUANE KORTHUIS ATC

Provider Business Mailing Address
First Line	:	1201 BRADLEY RD
Second Line	:
City	:	LYNDEN
State	:	WA
Zip	:	98264-9514
Country	:	US
Telephone Number	:	360-354-5387
Fax Number	:

Provider Business Practice Location Address
First Line	:	1201 BRADLEY RD.
Second Line	:	LYNDEN HIGH SCHOOL
City	:	LYNDEN
State	:	WA
Zip	:	98264
Country	:	US
Telephone Number	:	360-354-5387
Fax Number	:

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

Provider Enumeration Date	:	03/06/2014
Last Update Date	:	03/06/2014

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