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General NPI Number Information
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NPI Number | 1487252664
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Entity Type | Individual
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Provider Name | BRYCE MICHAEL HIETPAS LAT, ATC
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Gender | Male
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Dates
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Enumeration Date | 10/11/2020
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Last Update Date | 07/09/2022
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Provider Practice Location Address
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Address Line | 1 CAMPUS VIEW DR
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City | VIENNA
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State | WV
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Zip | 26105-8000
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Country | US
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Telephone | 304-865-6000
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Fax |
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Provider Business Mailing Address
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Address Line | 2301 LAKELAND HILLS BLVD
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City | LAKELAND
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State | FL
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Zip | 33805-2909
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Country | US
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Telephone | 920-636-8509
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AT001739
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License Number State | WV
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