Healthcare Provider Details

I. General information

NPI: 1144240326
Provider Name (Legal Business Name): JEFFERY BRENT HOGAN ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 11/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SHIELDS AVE ATHLETIC DEPT. UNIVERSITY OF CALIFORNIA
DAVIS CA
95616-5270
US

IV. Provider business mailing address

1 SHIELDS AVE ATHLETIC DEPT. UNIVERSITY OF CALIFORNIA
DAVIS CA
95616-5270
US

V. Phone/Fax

Practice location:
  • Phone: 530-752-0647
  • Fax: 530-752-6681
Mailing address:
  • Phone: 530-752-0647
  • Fax: 530-752-6681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: