MEDICARE: JOSHUA STORK ATC, LAT, MBA

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	36001441A	IN

General Provider Information

NPI Number	:	1942627963
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSHUA STORK ATC, LAT, MBA

Provider Business Mailing Address
First Line	:	11130 PARKVIEW CIRCLE DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-1735
Country	:	US
Telephone Number	:	260-249-9534
Fax Number	:

Provider Business Practice Location Address
First Line	:	3601 S CALHOUN ST
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46807-2006
Country	:	US
Telephone Number	:	260-249-9534
Fax Number	:

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

Provider Enumeration Date	:	03/27/2014
Last Update Date	:	03/02/2016

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