Provider Demographics
NPI:1437663754
Name:DORSTEN, DANE ROBERT (ATC LAT)
Entity Type:Individual
Prefix:
First Name:DANE
Middle Name:ROBERT
Last Name:DORSTEN
Suffix:
Gender:M
Credentials:ATC LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 W OSBORN RD STE 303
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-3820
Mailing Address - Country:US
Mailing Address - Phone:602-279-8022
Mailing Address - Fax:602-279-8029
Practice Address - Street 1:444 W OSBORN RD STE 303
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-3820
Practice Address - Country:US
Practice Address - Phone:602-279-8022
Practice Address - Fax:602-279-8029
Is Sole Proprietor?:No
Enumeration Date:2017-11-22
Last Update Date:2017-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ09442255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0944OtherARIZONA BOARD OF ATHLETIC TRAINING
60802411OtherBOARD OF CERTIFICATION (ATHLETIC TRAINING(