MEDICARE: ASHLEY FRANCIS WOLLAM ATC, LAT

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	6732817-4810	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	120602020	OTHER		NATIONAL ATHLETIC TRAINERS' ASSOCIATION BOARD OF CERTIFICATION

General Provider Information

NPI Number	:	1427325984
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ASHLEY FRANCIS WOLLAM ATC, LAT

Provider Business Mailing Address
First Line	:	225 S 700 E
Second Line	:
City	:	ST GEORGE
State	:	UT
Zip	:	84770-3875
Country	:	US
Telephone Number	:	253-370-8589
Fax Number	:

Provider Business Practice Location Address
First Line	:	3155 S HIDDEN VALLEY DR
Second Line	:	UNIT #343
City	:	ST GEORGE
State	:	UT
Zip	:	84790-6671
Country	:	US
Telephone Number	:	253-370-8589
Fax Number	:

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

Provider Enumeration Date	:	11/28/2011
Last Update Date	:	11/28/2011

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