Healthcare Provider Details

I. General information

NPI: 1497743892
Provider Name (Legal Business Name): ANTHONY FARMER SUTTON ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 10/08/2022
Certification Date: 10/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 WARREN CARROLL DRIVE WEISIGER-BROWN ATHLETIC FACILITY
RALEIGH NC
27695-2769
US

IV. Provider business mailing address

C113 JOYCE CENTER SPORTS MEDICINE
NOTRE DAME IN
46556
US

V. Phone/Fax

Practice location:
  • Phone: 919-515-2111
  • Fax: 919-513-0728
Mailing address:
  • Phone: 574-631-3303
  • Fax: 574-631-3305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberLAT-4057
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: