MEDICARE: MISTY LYNN MOTTER 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	RT003559	PA

General Provider Information

NPI Number	:	1639599111
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISTY LYNN MOTTER ATC

Provider Business Mailing Address
First Line	:	776 SMALLS FERRY RD
Second Line	:
City	:	ENON VALLEY
State	:	PA
Zip	:	16120-1324
Country	:	US
Telephone Number	:	724-971-6094
Fax Number	:	724-946-6297

Provider Business Practice Location Address
First Line	:	319 S MARKET ST
Second Line	:
City	:	NEW WILMINGTON
State	:	PA
Zip	:	16172-0002
Country	:	US
Telephone Number	:	724-971-6094
Fax Number	:	724-946-6297

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

Provider Enumeration Date	:	04/23/2014
Last Update Date	:	04/23/2014

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