Healthcare Provider Details

I. General information

NPI: 1558857201
Provider Name (Legal Business Name): BRYCE ANDREW ENSOR ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2018
Last Update Date: 07/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 E UNIVERSITY WAY
ELLENSBURG WA
98926-7500
US

IV. Provider business mailing address

24985 MONROE ROAD 217
HOLLIDAY MO
65258-2202
US

V. Phone/Fax

Practice location:
  • Phone: 509-963-3238
  • Fax:
Mailing address:
  • Phone: 573-473-0179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: