Bryan Joseph Domitrz, ATC, LAT

Primary specialty

Athletic TrainerTaxonomy code 2255A2300X

License

096.004969 Issued in IL

Practice address

501 N Parkside Rd
Normal, IL 61761-2780

Phone

(309) 557-4402

NPI assigned

Feb 16, 2021

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Electronic endpoints 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1613433600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1613433600000",
    "number": "1871186304",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "W792 POTTERS CIR",
            "city": "EAST TROY",
            "state": "WI",
            "postal_code": "531202317",
            "telephone_number": "414-828-4911"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "501 N PARKSIDE RD",
            "city": "NORMAL",
            "state": "IL",
            "postal_code": "617612780",
            "telephone_number": "309-557-4402"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DOMITRZ",
        "first_name": "BRYAN",
        "middle_name": "JOSEPH",
        "credential": "ATC, LAT",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2021-02-16",
        "last_updated": "2021-02-16",
        "certification_date": "2021-02-16",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2255A2300X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Specialist/Technologist, Athletic Trainer",
            "state": "IL",
            "license": "096.004969",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "NCWHS",
            "affiliation": "N",
            "address_1": "501 N Parkside Rd",
            "city": "Normal",
            "state": "IL",
            "country_code": "US",
            "postal_code": "617612780",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

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• Athletic Trainer in Normal, IL
• Providers in Normal, IL by specialty
• Athletic Trainer in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 16, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.