Healthcare Provider Details

I. General information

NPI: 1215205950
Provider Name (Legal Business Name): RAY YAMRUS JR. MS, VATL, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2011
Last Update Date: 04/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 UNIVERSITY DR INTERCOLLEGIATE ATHLETICS - MS 3A5
FAIRFAX VA
22030-4422
US

IV. Provider business mailing address

4400 UNIVERSITY DR INTERCOLLEGIATE ATHLETICS - MS 3A5
FAIRFAX VA
22030-4422
US

V. Phone/Fax

Practice location:
  • Phone: 703-993-3280
  • Fax: 703-993-3360
Mailing address:
  • Phone: 703-993-3280
  • Fax: 703-993-3360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0126 000385
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: