MEDICARE: MR. NATHANIEL SUCHYNA A.T.C.

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	001189	NY

General Provider Information

NPI Number	:	1437558905
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. NATHANIEL SUCHYNA A.T.C.

Provider Business Mailing Address
First Line	:	4129 LAKE SHORE RD
Second Line	:
City	:	ATHOL SPRINGS
State	:	NY
Zip	:	14010-1712
Country	:	US
Telephone Number	:	716-627-1200
Fax Number	:	716-627-4610

Provider Business Practice Location Address
First Line	:	4129 LAKE SHORE RD
Second Line	:
City	:	ATHOL SPRINGS
State	:	NY
Zip	:	14010-1712
Country	:	US
Telephone Number	:	716-627-1200
Fax Number	:	716-627-4610

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

Provider Enumeration Date	:	08/20/2014
Last Update Date	:	08/20/2014

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