Provider Demographics
NPI:1457310153
Name:FEDYSHIN, MICHAEL JAMES (ATC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JAMES
Last Name:FEDYSHIN
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22633 PHILLIPS DR
Mailing Address - Street 2:
Mailing Address - City:PLEASANTVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16341-9658
Mailing Address - Country:US
Mailing Address - Phone:814-589-7363
Mailing Address - Fax:
Practice Address - Street 1:534 E PLEASANT ST
Practice Address - Street 2:
Practice Address - City:CORRY
Practice Address - State:PA
Practice Address - Zip Code:16407-2246
Practice Address - Country:US
Practice Address - Phone:814-665-8297
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART000421A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer