Healthcare Provider Details

I. General information

NPI: 1477596963
Provider Name (Legal Business Name): TREVOR D HOLMAN ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 04/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3303 SW BOND AVE MAIL CODE: CH3T OREGON HEALTH & SCIENCES UNIVERSITY
PORTLAND OR
97239
US

IV. Provider business mailing address

14655 KASEL CT NE
AURORA OR
97002-9445
US

V. Phone/Fax

Practice location:
  • Phone: 503-418-2406
  • Fax:
Mailing address:
  • Phone: 503-789-4221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT-AT-750170
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: