MEDICARE: MR. VALDEZ CROUSE LAT, 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	RT0052254	PA

General Provider Information

NPI Number	:	1447039003
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. VALDEZ CROUSE LAT, ATC

Provider Business Mailing Address
First Line	:	1785 BISHOP WHITE DR
Second Line	:
City	:	NEWTOWN SQUARE
State	:	PA
Zip	:	19073-1300
Country	:	US
Telephone Number	:	484-424-1418
Fax Number	:

Provider Business Practice Location Address
First Line	:	1785 BISHOP WHITE DR
Second Line	:
City	:	NEWTOWN SQUARE
State	:	PA
Zip	:	19073-1300
Country	:	US
Telephone Number	:	484-424-1411
Fax Number	:

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

Provider Enumeration Date	:	09/25/2023
Last Update Date	:	01/23/2025

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