Healthcare Provider Details

I. General information

NPI: 1124649348
Provider Name (Legal Business Name): URIYAH A MATHIS LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2020
Last Update Date: 11/21/2022
Certification Date: 11/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2449 STAGECOACH RD
OGLETHORPE GA
31068-8425
US

IV. Provider business mailing address

61 SHERRI LN
TIFTON GA
31794-9452
US

V. Phone/Fax

Practice location:
  • Phone: 478-555-5555
  • Fax:
Mailing address:
  • Phone: 229-733-2878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2000036522
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: