Provider Demographics
NPI:1710418488
Name:FICHTNER, DALLAS (LAT, ATC)
Entity type:Individual
Prefix:
First Name:DALLAS
Middle Name:
Last Name:FICHTNER
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 SAINT PAUL AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68504-2760
Mailing Address - Country:US
Mailing Address - Phone:402-465-7545
Mailing Address - Fax:402-465-2170
Practice Address - Street 1:5000 SAINT PAUL AVE
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68504-2760
Practice Address - Country:US
Practice Address - Phone:402-465-7545
Practice Address - Fax:402-465-2170
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-24
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE4472255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
070502260OtherBOARD OF CERTIFICATION ATHLETIC TRAINING CERTIFIED
NE447OtherDEPARTMENT OF HEALTH AND HUMAN SERVICES ATHLETIC TRAINING LICENSE