Provider Demographics
NPI:1790429991
Name:VERNON, EWELL R (ATC)
Entity type:Individual
Prefix:
First Name:EWELL
Middle Name:R
Last Name:VERNON
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 1:1029 OAK RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CANA
Mailing Address - State:VA
Mailing Address - Zip Code:24317-4160
Mailing Address - Country:US
Mailing Address - Phone:336-648-5211
Mailing Address - Fax:
Practice Address - Street 1:1029 OAK RIDGE RD
Practice Address - Street 2:
Practice Address - City:CANA
Practice Address - State:VA
Practice Address - Zip Code:24317-4160
Practice Address - Country:US
Practice Address - Phone:336-648-5211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-24
Last Update Date:2022-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLAT-25872255A2300X
VA01260016162255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer