MEDICARE: JUSTIN NIXON 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

General Provider Information

NPI Number	:	1922652437
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUSTIN NIXON ATC,LAT

Provider Business Mailing Address
First Line	:	1105 TOWN BLVD NE UNIT 2502
Second Line	:
City	:	BROOKHAVEN
State	:	GA
Zip	:	30319-3678
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3240 NORTHEAST EXPY NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30341-4003
Country	:	US
Telephone Number	:	770-286-4987
Fax Number	:

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

Provider Enumeration Date	:	08/01/2019
Last Update Date	:	08/01/2019

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