Provider Demographics
NPI:1487302592
Name:BANE, TIM M (ATC)
Entity type:Individual
Prefix:MR
First Name:TIM
Middle Name:M
Last Name:BANE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:1092 WINTER WREN ST
Mailing Address - Street 2:
Mailing Address - City:GRUNDY
Mailing Address - State:VA
Mailing Address - Zip Code:24614-5770
Mailing Address - Country:US
Mailing Address - Phone:540-632-9184
Mailing Address - Fax:
Practice Address - Street 1:1092 WINTER WREN ST
Practice Address - Street 2:
Practice Address - City:GRUNDY
Practice Address - State:VA
Practice Address - Zip Code:24614-5770
Practice Address - Country:US
Practice Address - Phone:540-632-9184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-17
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260003412255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
812463OtherNATIONAL ATHLETIC TRAINERS ASSOCIATION BOC