Healthcare Provider Details

I. General information

NPI: 1629423629
Provider Name (Legal Business Name): TIMOTHY HUPP ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2016
Last Update Date: 03/07/2023
Certification Date: 03/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 CHILDRENS LN
NORFOLK VA
23507-1910
US

IV. Provider business mailing address

7437 MAJOR AVE
NORFOLK VA
23505-3021
US

V. Phone/Fax

Practice location:
  • Phone: 757-609-5346
  • Fax:
Mailing address:
  • Phone: 757-609-5346
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0126002832
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: