Healthcare Provider Details

I. General information

NPI: 1902023161
Provider Name (Legal Business Name): THOMAS WILLIAM OBRIEN MA,ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4513 MONUMENT AVE
RICHMOND VA
23230
US

IV. Provider business mailing address

4513 MONUMENT AVE
RICHMOND VA
23230
US

V. Phone/Fax

Practice location:
  • Phone: 804-359-0369
  • Fax:
Mailing address:
  • Phone: 804-359-0369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0126000031
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: