Provider Demographics
NPI:1649742859
Name:MAGGIO, ERIC JASON (LAT ATC)
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:JASON
Last Name:MAGGIO
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 1:1917 W PARK DR
Mailing Address - Street 2:
Mailing Address - City:NORTH WILKESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28659-3585
Mailing Address - Country:US
Mailing Address - Phone:336-414-5181
Mailing Address - Fax:
Practice Address - Street 1:1917 W PARK DR
Practice Address - Street 2:
Practice Address - City:NORTH WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28659-3585
Practice Address - Country:US
Practice Address - Phone:336-414-5181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-28
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC05032255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer