Healthcare Provider Details

I. General information

NPI: 1083727739
Provider Name (Legal Business Name): BRYN CHRISTOPHER VANPATTEN PHD, ATC, CSCS, EMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 05/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PROVIDENCE COLLEGE 1 CUNNINGHAM SQ CANAVAN SPORTS MEDICINE CENTER - ALUMNI HALL
PROVIDENCE RI
02918-0001
US

IV. Provider business mailing address

1 UNIVERSITY PLZ
BROOKLYN NY
11201-5301
US

V. Phone/Fax

Practice location:
  • Phone: 401-865-2251
  • Fax: 401-865-2965
Mailing address:
  • Phone: 401-569-3867
  • Fax: 718-780-6539

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT00244
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number709
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code146M00000X
TaxonomyIntermediate Emergency Medical Technician
License NumberEMT14833
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: