MEDICARE: MR. MATTHEW JEROME BUSSMAN A.T.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	A1 60047682	WA

General Provider Information

NPI Number	:	1235376369
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MATTHEW JEROME BUSSMAN A.T.C.

Provider Business Mailing Address
First Line	:	901 12TH AVENUE
Second Line	:	PO BOX 222000
City	:	SEATTLE
State	:	WA
Zip	:	98122
Country	:	US
Telephone Number	:	206-296-5432
Fax Number	:	206-296-2154

Provider Business Practice Location Address
First Line	:	901 12TH AVE
Second Line	:	ATHLETICS BUILDING
City	:	SEATTLE
State	:	WA
Zip	:	98122-4411
Country	:	US
Telephone Number	:	206-296-5432
Fax Number	:	206-296-2154

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/12/2009
Last Update Date	:	01/12/2009

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