Provider Demographics
NPI:1891705026
Name:BUITRAGO, ERICK A (MSED, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:ERICK
Middle Name:A
Last Name:BUITRAGO
Suffix:
Gender:M
Credentials:MSED, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7979 SWEETWATER CT
Mailing Address - Street 2:APT. N
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-9503
Mailing Address - Country:US
Mailing Address - Phone:812-237-4066
Mailing Address - Fax:812-237-9612
Practice Address - Street 1:ATHLETIC TRAINING DEPARTMENT
Practice Address - Street 2:ARENA RM B-17
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47809-0001
Practice Address - Country:US
Practice Address - Phone:812-237-4066
Practice Address - Fax:812-237-9612
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36001258A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN36001258AOtherATHLETIC TRAINER LICENSE