Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081S0010X | Sports Medicine | AT7014 | TX |
Y | 213ES0000X | Sports Medicine | AT7014 | TX |
NPI | 1144873415 |
---|---|
Provider Name | Brady Clinton Tomlin |
First Address | Longview, TX 75602-3564 |
Second Address | Longview, TX 75602-3564 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/07/2019 |
Last Update Date | 16/07/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2000024206 | BOC CERTIFICATION NUMBER (01) | |
AT7014 | TEXAS LICENSED ATHLETIC TRAINER (01) | TX |