Healthcare Provider Details

I. General information

NPI: 1124536313
Provider Name (Legal Business Name): WILLIAM MESTAS ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2018
Last Update Date: 01/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3125 WRIGHT ST
SELMA CA
93662-2429
US

IV. Provider business mailing address

5232 DAVINA WAY
KEYES CA
95328-8405
US

V. Phone/Fax

Practice location:
  • Phone: 559-903-9231
  • Fax:
Mailing address:
  • Phone: 209-216-8422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2000029470
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: