MEDICARE: ADAM S MISTR ATC, LAT

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	1008	SC
2	2255A2300X	Athletic Trainer	0126000729	VA

General Provider Information

NPI Number	:	1215183819
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ADAM S MISTR ATC, LAT

Provider Business Mailing Address
First Line	:	1272 MILL DAM RD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23454-2322
Country	:	US
Telephone Number	:	757-496-6719
Fax Number	:

Provider Business Practice Location Address
First Line	:	1272 MILL DAM RD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23454-2322
Country	:	US
Telephone Number	:	757-496-6719
Fax Number	:

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

Provider Enumeration Date	:	08/14/2008
Last Update Date	:	09/10/2019

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