=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366430118
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANIEL A DUFFY LAT, ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2005
-----------------------------------------------------
Last Update Date | 10/08/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6019 OLEANDER DRIVE SUITE 101
-----------------------------------------------------
City | WILMINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-791-0001
-----------------------------------------------------
Fax | 910-791-6888
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 370 RL HONEYCUTT DRIVE
-----------------------------------------------------
City | WILMINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-612-0278
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 0099
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------