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General NPI Number Information
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NPI Number | 1548650252
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Entity Type | Individual
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Provider Name | OCTAVIA KARRA MATHIS ATC
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Gender | Female
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Dates
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Enumeration Date | 02/02/2015
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Last Update Date | 02/02/2015
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Provider Practice Location Address
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Address Line | 192 YELLOWSTONE DR APT 308
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City | CHARLOTTESVILLE
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State | VA
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Zip | 22903-8120
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Country | US
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Telephone | 757-404-1810
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Fax |
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Provider Business Mailing Address
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Address Line | 5337 CHATHAM HALL DR
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City | VIRGINIA BEACH
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State | VA
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Zip | 23464-5428
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Country | US
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Telephone | 757-404-1810
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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 | 0126002205
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License Number State | VA
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