Healthcare Provider Details

I. General information

NPI: 1528638574
Provider Name (Legal Business Name): WILLIAM MICHAEL O'BRYAN VI ATC, LAT, MSAT, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2021
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3326 E BADGER RD
EVERSON WA
98247-9232
US

IV. Provider business mailing address

3791 MT BAKER HWY
EVERSON WA
98247-9406
US

V. Phone/Fax

Practice location:
  • Phone: 360-988-4754
  • Fax:
Mailing address:
  • Phone: 360-389-0257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberATHL.A1.61474097
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: