=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033174321
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANNA THAMES RANDA ATC, NREMT-I
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2006
-----------------------------------------------------
Last Update Date | 12/02/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 SMITH STREET UGA SPORTS MEDICINE DEPARTMENT
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30603-1472
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-542-7892
-----------------------------------------------------
Fax | 706-542-7707
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1472 UGA SPORTS MEDICINE DEPARTMENT
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30603-1472
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-542-7892
-----------------------------------------------------
Fax | 706-542-7707
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | AT000963
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------