MEDICARE: PAT A DIOGUARDO ATC CSCS

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	25MT00041800	NJ

General Provider Information

NPI Number	:	1962565770
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAT A DIOGUARDO ATC CSCS

Provider Business Mailing Address
First Line	:	306 W CONNECTICUT AVE
Second Line	:
City	:	SOMERS POINT
State	:	NJ
Zip	:	08244-1906
Country	:	US
Telephone Number	:	609-653-8780
Fax Number	:

Provider Business Practice Location Address
First Line	:	306 W CONNECTICUT AVE
Second Line	:
City	:	SOMERS POINT
State	:	NJ
Zip	:	08244-1906
Country	:	US
Telephone Number	:	609-653-8780
Fax Number	:

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

Provider Enumeration Date	:	12/19/2006
Last Update Date	:	07/09/2007

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