Healthcare Provider Details

I. General information

NPI: 1831467893
Provider Name (Legal Business Name): MICHAEL METHVIN M.ED., ATC, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2011
Last Update Date: 08/23/2021
Certification Date: 08/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 OSS/OHWS (PACAF) UNIT 2163
APO AP
96278-2163
US

IV. Provider business mailing address

PSC 3 BOX 6046
APO AP
96266-0061
US

V. Phone/Fax

Practice location:
  • Phone: 108-466-8106
  • Fax:
Mailing address:
  • Phone: 108-466-8106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL3061
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberATR-001492
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: