MEDICARE: JERRY DANIEL WHEAT 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	0329	TX

General Provider Information

NPI Number	:	1629142823
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERRY DANIEL WHEAT ATC, LAT

Provider Business Mailing Address
First Line	:	2109 LINCOLN CT
Second Line	:
City	:	FLOWER MOUND
State	:	TX
Zip	:	75028-8363
Country	:	US
Telephone Number	:	972-691-2625
Fax Number	:

Provider Business Practice Location Address
First Line	:	3700 W BERRY
Second Line	:	LUPTON STADIUM
City	:	FORT WORTH
State	:	TX
Zip	:	76129-0001
Country	:	US
Telephone Number	:	817-257-5156
Fax Number	:

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

Provider Enumeration Date	:	11/20/2006
Last Update Date	:	07/08/2007

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