MEDICARE: MR. STEPHAN MILO WALZ 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	AL75	FL

General Provider Information

NPI Number	:	1669444188
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. STEPHAN MILO WALZ ATC

Provider Business Mailing Address
First Line	:	4604 GLENSIDE CIR
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33624-4312
Country	:	US
Telephone Number	:	813-908-6873
Fax Number	:

Provider Business Practice Location Address
First Line	:	4202 E FOWLER AVE
Second Line	:	ATH100
City	:	TAMPA
State	:	FL
Zip	:	33620-8001
Country	:	US
Telephone Number	:	813-974-3506
Fax Number	:	813-974-8541

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

Provider Enumeration Date	:	02/07/2006
Last Update Date	:	05/30/2019

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