Provider Demographics
NPI:1487048351
Name:ROST, JUSTIN MICHAEL (ATC, CSCS, MSE)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:MICHAEL
Last Name:ROST
Suffix:
Gender:M
Credentials:ATC, CSCS, MSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29353 LINDBERGH LN
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:MN
Mailing Address - Zip Code:56310-9672
Mailing Address - Country:US
Mailing Address - Phone:952-221-6810
Mailing Address - Fax:
Practice Address - Street 1:2850 ABBEY PLAZA
Practice Address - Street 2:
Practice Address - City:COLLEGEVILLE
Practice Address - State:MN
Practice Address - Zip Code:56321
Practice Address - Country:US
Practice Address - Phone:320-363-3105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-27
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN24912255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2491OtherATHLETIC TRAINER