MEDICARE: MR. BRYAN WAYNE HOUSAND 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	0126001103	VA
2	2255A2300X	Athletic Trainer	0012	NC

General Provider Information

NPI Number	:	1952408650
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRYAN WAYNE HOUSAND ATC

Provider Business Mailing Address
First Line	:	1715 WINTHROP LN
Second Line	:
City	:	MONROE
State	:	NC
Zip	:	28110-5206
Country	:	US
Telephone Number	:	412-389-9636
Fax Number	:

Provider Business Practice Location Address
First Line	:	1715 WINTHROP LN
Second Line	:
City	:	MONROE
State	:	NC
Zip	:	28110-5206
Country	:	US
Telephone Number	:	412-389-9636
Fax Number	:

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

Provider Enumeration Date	:	09/17/2006
Last Update Date	:	01/19/2010

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