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General NPI Number Information
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NPI Number | 1538436258
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Entity Type | Individual
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Provider Name | NICHOLAS LEE BOHANAN ATC, CSCS
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Gender | Male
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Dates
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Enumeration Date | 11/23/2011
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Last Update Date | 11/23/2011
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Provider Practice Location Address
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Address Line | 621 SIX FLAGS DR
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City | ARLINGTON
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State | TX
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Zip | 76011-6305
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Country | US
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Telephone | 817-385-8285
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Fax | 817-385-8261
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Provider Business Mailing Address
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Address Line | 2708 MARTIN DR APT 3065
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City | BEDFORD
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State | TX
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Zip | 76021-5044
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Country | US
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Telephone | 316-648-8525
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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 | AT4733
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License Number State | TX
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