=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366915464
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTOPHER GRIFFIS PA-C, LAT, ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2019
-----------------------------------------------------
Last Update Date | 03/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6712 CRABAPPLE ST
-----------------------------------------------------
City | LA VISTA
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68128-4353
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-323-6836
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6712 CRABAPPLE ST
-----------------------------------------------------
City | LA VISTA
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68128-4353
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-323-6836
-----------------------------------------------------
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 | AL5725
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 1169
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 3239
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------