=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053505909
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIAN C HAM ARNP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2007
-----------------------------------------------------
Last Update Date | 01/27/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 409 HIGH ST
-----------------------------------------------------
City | CHATTAHOOCHEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32324-1303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-663-4643
-----------------------------------------------------
Fax | 850-663-2350
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 409 HIGH ST
-----------------------------------------------------
City | CHATTAHOOCHEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32324-1303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-663-4643
-----------------------------------------------------
Fax | 850-663-2350
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | ARNP3033052
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------