Provider Demographics
NPI:1144873415
Name:TOMLIN, BRADY CLINTON (ATC, LAT, MS)
Entity type:Individual
Prefix:
First Name:BRADY
Middle Name:CLINTON
Last Name:TOMLIN
Suffix:
Gender:M
Credentials:ATC, LAT, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 S MOBBERLY AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75602-3564
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2100 S MOBBERLY AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75602-3564
Practice Address - Country:US
Practice Address - Phone:903-233-3794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-16
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT70142081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAT7014OtherTEXAS LICENSED ATHLETIC TRAINER
2000024206OtherBOC CERTIFICATION NUMBER