Provider Demographics
NPI:1710596093
Name:KISTLER, TREVOR LANE (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:LANE
Last Name:KISTLER
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:PO BOX 653
Mailing Address - Street 2:
Mailing Address - City:IRAAN
Mailing Address - State:TX
Mailing Address - Zip Code:79744-0653
Mailing Address - Country:US
Mailing Address - Phone:817-721-2048
Mailing Address - Fax:
Practice Address - Street 1:600 TX-349
Practice Address - Street 2:
Practice Address - City:IRAAN
Practice Address - State:TX
Practice Address - Zip Code:79744
Practice Address - Country:US
Practice Address - Phone:432-639-2575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-23
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT69832255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer