MEDICARE: MR. MICHAEL SHAWN WHITLEY JR. 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	0126002207	VA

General Provider Information

NPI Number	:	1922472158
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICHAEL SHAWN WHITLEY JR. ATC

Provider Business Mailing Address
First Line	:	5309 COMMONWEALTH CENTRE PKWY STE 100
Second Line	:
City	:	MIDLOTHIAN
State	:	VA
Zip	:	23112-2633
Country	:	US
Telephone Number	:	804-545-7560
Fax Number	:

Provider Business Practice Location Address
First Line	:	5309 COMMONWEALTH CENTRE PKWY STE 100
Second Line	:
City	:	MIDLOTHIAN
State	:	VA
Zip	:	23112-2633
Country	:	US
Telephone Number	:	804-545-7560
Fax Number	:

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

Provider Enumeration Date	:	11/27/2015
Last Update Date	:	11/27/2015

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