MEDICARE: NATHAN A VANRADEN 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	096.002607	IL

General Provider Information

NPI Number	:	1467753574
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NATHAN A VANRADEN ATC

Provider Business Mailing Address
First Line	:	14421 W MELBOURNE PL
Second Line	:
City	:	LOCKPORT
State	:	IL
Zip	:	60441-6016
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5700 COLLEGE RD
Second Line	:
City	:	LISLE
State	:	IL
Zip	:	60532-0900
Country	:	US
Telephone Number	:	630-829-6154
Fax Number	:	630-839-3696

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

Provider Enumeration Date	:	11/04/2010
Last Update Date	:	01/07/2019

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