Provider Demographics
NPI:1831467893
Name:METHVIN, MICHAEL (MED, ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:METHVIN
Suffix:
Gender:M
Credentials:MED, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 3 BOX 6046
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96266-0061
Mailing Address - Country:US
Mailing Address - Phone:108-466-8106
Mailing Address - Fax:
Practice Address - Street 1:51 OSS/OHWS (PACAF) UNIT 2163
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96278-2163
Practice Address - Country:US
Practice Address - Phone:108-466-8106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-06
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL30612255A2300X
AZATR-0014922255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000002093OtherBOC