Provider Demographics
NPI:1487252664
Name:HIETPAS, BRYCE MICHAEL (LAT, ATC)
Entity type:Individual
Prefix:MR
First Name:BRYCE
Middle Name:MICHAEL
Last Name:HIETPAS
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 LAKELAND HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-2909
Mailing Address - Country:US
Mailing Address - Phone:920-636-8509
Mailing Address - Fax:
Practice Address - Street 1:1 CAMPUS VIEW DR
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:WV
Practice Address - Zip Code:26105-8000
Practice Address - Country:US
Practice Address - Phone:304-865-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-11
Last Update Date:2022-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAT0017392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000039304OtherBOC CERTIFIED ATHLETIC TRAINER
WVAT001739OtherLICENSED ATHLETIC TRAINER