Healthcare Provider Details

I. General information

NPI: 1073197679
Provider Name (Legal Business Name): MICHAEL SHANE TIERNEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2021
Last Update Date: 05/10/2021
Certification Date: 05/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1633 DAVIDSON RD
MC LEAN VA
22101-4399
US

IV. Provider business mailing address

1633 DAVIDSON RD
MC LEAN VA
22101-4399
US

V. Phone/Fax

Practice location:
  • Phone: 703-714-5771
  • Fax:
Mailing address:
  • Phone: 703-714-5771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0126001718
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: