=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801869763
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID JERRELL WEIR ATC, LAT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/10/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | TEXAS A&M ATHLETIC DEPARTMENT POB 30017
-----------------------------------------------------
City | COLLEGE STATION
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77842-3017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-458-3662
-----------------------------------------------------
Fax | 979-847-8514
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1609 BLUE QUAIL LN
-----------------------------------------------------
City | COLLEGE STATION
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77845-6113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-764-9347
-----------------------------------------------------
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 | AT1144
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------