=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811347149
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MURPHY MARK LUATUA MS, LAT, ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2016
-----------------------------------------------------
Last Update Date | 06/17/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 844 WASHINGTON RD SUITE 101
-----------------------------------------------------
City | WESTMINSTER
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21157-6664
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-876-5600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9107 THISTLEDOWN RD APT. 167
-----------------------------------------------------
City | OWINGS MILLS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21117-8255
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | A0000468
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------