Provider Demographics
NPI:1215183819
Name:MISTR, ADAM S (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:S
Last Name:MISTR
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1272 MILL DAM RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-2322
Mailing Address - Country:US
Mailing Address - Phone:757-496-6719
Mailing Address - Fax:
Practice Address - Street 1:1272 MILL DAM RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-2322
Practice Address - Country:US
Practice Address - Phone:757-496-6719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-14
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10082255A2300X
VA01260007292255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer