MEDICARE: ANGELA ROSE BRAZIL-MENARD MAT, LAT, ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	1131	NE

General Provider Information

NPI Number	:	1073187084
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELA ROSE BRAZIL-MENARD MAT, LAT, ATC

Provider Business Mailing Address
First Line	:	1013 DAY DR
Second Line	:
City	:	BELLEVUE
State	:	NE
Zip	:	68005-4425
Country	:	US
Telephone Number	:	650-888-7612
Fax Number	:

Provider Business Practice Location Address
First Line	:	11901 PACIFIC ST
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68154-3421
Country	:	US
Telephone Number	:	402-401-6151
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/14/2021
Last Update Date	:	01/06/2023

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