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NPI Code Detail

MEDICARE: MR. BRYCE MICHAEL HIETPAS LAT, ATC

MEDICARE: MR. BRYCE MICHAEL HIETPAS LAT, ATC
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
12255A2300XAthletic TrainerAT001739WV

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
12000039304OTHERBOC CERTIFIED ATHLETIC TRAINER
2AT001739OTHERWVLICENSED ATHLETIC TRAINER

General Provider Information

NPI Number : 1487252664
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. BRYCE MICHAEL HIETPAS LAT, ATC
Provider Business Mailing Address
First Line : 2301 LAKELAND HILLS BLVD
Second Line :
City : LAKELAND
State : FL
Zip : 33805-2909
Country : US
Telephone Number : 920-636-8509
Fax Number :
Provider Business Practice Location Address
First Line : 1 CAMPUS VIEW DR
Second Line :
City : VIENNA
State : WV
Zip : 26105-8000
Country : US
Telephone Number : 304-865-6000
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/11/2020
Last Update Date : 07/09/2022

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