=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649300849
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMES GLEN LANCASTER ATC, LAT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2007
-----------------------------------------------------
Last Update Date | 09/06/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1201 W UNIVERSITY DR DEPT. OF INTERCOLLEGIATE ATHLETICS
-----------------------------------------------------
City | EDINBURG
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78539-2909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-665-2233
-----------------------------------------------------
Fax | 956-665-7200
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1013 DIANA DR
-----------------------------------------------------
City | EDINBURG
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78542-5120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-381-8557
-----------------------------------------------------
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 | AT0560
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------