Provider Demographics
NPI:1124557350
Name:NITZ, BRIAN STEPHEN (ATC)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:STEPHEN
Last Name:NITZ
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2203 W GRANITE ST
Mailing Address - Street 2:
Mailing Address - City:SILOAM SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72761-3315
Mailing Address - Country:US
Mailing Address - Phone:479-220-2964
Mailing Address - Fax:
Practice Address - Street 1:700 N PROGRESS AVE
Practice Address - Street 2:
Practice Address - City:SILOAM SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72761-4349
Practice Address - Country:US
Practice Address - Phone:479-524-5134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-10
Last Update Date:2017-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAT3852255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
885931099OtherNATIONAL ATHLETIC TRAINERS ASSOC. BOARD OF CERTIFICATION