MEDICARE: RON STEVEN KORDONOWY AT

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	0263	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0263	OTHER	AZ	ARIZONA BOARD OF ATHLETIC TRAINING

General Provider Information

NPI Number	:	1720485667
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RON STEVEN KORDONOWY AT

Provider Business Mailing Address
First Line	:	3849 W ACAPULCO LN
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85053-4517
Country	:	US
Telephone Number	:	602-318-7606
Fax Number	:	623-915-8560

Provider Business Practice Location Address
First Line	:	3849 W ACAPULCO LN
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85053-4517
Country	:	US
Telephone Number	:	602-318-7606
Fax Number	:	623-915-8560

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

Provider Enumeration Date	:	11/20/2014
Last Update Date	:	11/20/2014

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