Provider Demographics
NPI:1811927254
Name:WOOD, IAN A (ATC)
Entity type:Individual
Prefix:MR
First Name:IAN
Middle Name:A
Last Name:WOOD
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 DENT DR
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17837-2005
Mailing Address - Country:US
Mailing Address - Phone:570-577-1056
Mailing Address - Fax:
Practice Address - Street 1:1 DENT DR
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:PA
Practice Address - Zip Code:17837-2005
Practice Address - Country:US
Practice Address - Phone:570-577-1056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2017-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7672255A2300X
WI96-0392255A2300X
IN36000152A2255A2300X
NY000153-12255A2300X
PART001549A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
069402484OtherBOARD OF CERTIFICATION FOR ATHLETIC TRAINING
PART001549AOtherSTATE ATHLETIC TRAINING LICENSE