Provider Demographics
NPI:1760474209
Name:MARICHAK, ROBIN MICHELLE (ATHLETIC TRAINER)
Entity Type:Individual
Prefix:
First Name:ROBIN
Middle Name:MICHELLE
Last Name:MARICHAK
Suffix:
Gender:F
Credentials:ATHLETIC TRAINER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 HILLSIDE ST
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702-6406
Mailing Address - Country:US
Mailing Address - Phone:570-826-0922
Mailing Address - Fax:
Practice Address - Street 1:1000 E MOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18711-0027
Practice Address - Country:US
Practice Address - Phone:570-820-6086
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART002124A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist