Provider Demographics
NPI:1801219548
Name:BACON, ANDREW MICHAEL (MS, AT, ATC)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:MICHAEL
Last Name:BACON
Suffix:
Gender:M
Credentials:MS, AT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 COLLEGE PARK CRONIN ATHLETIC CENTER ROOM 101
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45469-0001
Mailing Address - Country:US
Mailing Address - Phone:951-541-4697
Mailing Address - Fax:937-229-5448
Practice Address - Street 1:300 COLLEGE PARK CRONIN ATHLETIC CENTER ROOM 101
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45469-0001
Practice Address - Country:US
Practice Address - Phone:951-541-4697
Practice Address - Fax:937-229-5448
Is Sole Proprietor?:No
Enumeration Date:2014-01-31
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH004263174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000007147OtherNATIONAL ATHLETIC TRAINERS' ASSOCIATION BOARD OF CERTIFIACTION