=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598540163
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRANDON JOSEPH LEE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2023
-----------------------------------------------------
Last Update Date | 06/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15433 PLANTATION OAKS DR APT 15
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33647-2130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-284-9578
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6814 DRIFTWOOD DR
-----------------------------------------------------
City | HUDSON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34667-1035
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-284-9578
-----------------------------------------------------
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 | 7212
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------