Provider Demographics
NPI:1225545411
Name:BRUCKNER, JUSTIN ADAM (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ADAM
Last Name:BRUCKNER
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 PINE AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-2707
Mailing Address - Country:US
Mailing Address - Phone:631-456-1779
Mailing Address - Fax:
Practice Address - Street 1:777 PINE AVE
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-2707
Practice Address - Country:US
Practice Address - Phone:631-456-1779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-09
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PARTO0005062255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program