Basic Information
| Provider Information | |||||||||
| NPI: | 1922724558 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRICKER | ||||||||
| FirstName: | CAMARYN | ||||||||
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| Credential: | LAT, ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 180 EDYTHE ST | ||||||||
| Address2: | |||||||||
| City: | LIVERMORE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945504019 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 520 S EAGLE RD STE 3213 | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836426356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087065000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2022 | ||||||||
| LastUpdateDate: | 10/14/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | AT-840 | ID | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
ID Information
| ID | Type | State | Issuer | Description | AT-840 | 01 | ID | IDAHO BOARD OF MEDICINE | OTHER | 2000051191 | 01 | ID | NATA BOARD OF CERTIFICATION | OTHER |