MEDICARE: BRIAN WRIGHT ATC, VATL

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	0126001621	VA

General Provider Information

NPI Number	:	1770995227
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN WRIGHT ATC, VATL

Provider Business Mailing Address
First Line	:	505 BUFFER CT
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23462-4504
Country	:	US
Telephone Number	:	757-418-2095
Fax Number	:

Provider Business Practice Location Address
First Line	:	2425 SHOREHAVEN DR
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23454-1749
Country	:	US
Telephone Number	:	757-648-5250
Fax Number	:

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

Provider Enumeration Date	:	06/02/2014
Last Update Date	:	06/02/2014

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