Healthcare Provider Details

I. General information

NPI: 1427507193
Provider Name (Legal Business Name): MEGAN PETERS LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MEGAN STYRON

II. Dates (important events)

Enumeration Date: 09/22/2016
Last Update Date: 06/27/2022
Certification Date: 06/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8000 FL-64
BRADENTON FL
34212
US

IV. Provider business mailing address

108 COROT DR
NOKOMIS FL
34275-4225
US

V. Phone/Fax

Practice location:
  • Phone: 941-792-1404
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number6286
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: