Healthcare Provider Details

I. General information

NPI: 1972019727
Provider Name (Legal Business Name): MICHAEL WAYNE HILLIARD ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2017
Last Update Date: 03/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

649 17TH ST S
MOORHEAD MN
56560
US

IV. Provider business mailing address

649 17TH ST S
MOORHEAD MN
56560
US

V. Phone/Fax

Practice location:
  • Phone: 360-751-9904
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2826
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: