Healthcare Provider Details

I. General information

NPI: 1992532287
Provider Name (Legal Business Name): BRANDON MARLIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2024
Last Update Date: 09/19/2024
Certification Date: 09/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4535 GRAHAM DR
CONWAY AR
72034-8205
US

IV. Provider business mailing address

4535 GRAHAM DR
CONWAY AR
72034-8205
US

V. Phone/Fax

Practice location:
  • Phone: 501-514-1393
  • Fax:
Mailing address:
  • Phone: 501-514-1393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: