MEDICARE: MS. RAQUEL ELISE MARTIN 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	0126000879	VA

General Provider Information

NPI Number	:	1275656043
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. RAQUEL ELISE MARTIN ATC

Provider Business Mailing Address
First Line	:	5124 NORTH 9TH STREET
Second Line	:
City	:	ARLINGTON
State	:	VA
Zip	:	22205
Country	:	US
Telephone Number	:	804-519-6849
Fax Number	:

Provider Business Practice Location Address
First Line	:	5124 NORTH 9TH STREET
Second Line	:
City	:	ARLINGTON
State	:	VA
Zip	:	22205
Country	:	US
Telephone Number	:	804-519-6849
Fax Number	:

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

Provider Enumeration Date	:	04/09/2007
Last Update Date	:	12/26/2012

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