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NPI Code Detail

MEDICARE: MONICA ANN WAGNER LAT

MEDICARE: MONICA ANN WAGNER LAT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12255A2300XAthletic Trainer345039WI

General Provider Information

NPI Number : 1366438335
Entity Type Code : Individual
Provider Name (Legal Business Name) : MONICA ANN WAGNER LAT
Provider Business Mailing Address
First Line : 8069 COUNTY ROAD A
Second Line :
City : LENA
State : WI
Zip : 54139-9737
Country : US
Telephone Number : 920-842-3280
Fax Number : 920-430-4746
Provider Business Practice Location Address
First Line : 1630 COMMANCHE AVE
Second Line :
City : GREEN BAY
State : WI
Zip : 54313-5753
Country : US
Telephone Number : 920-430-4750
Fax Number : 920-430-4746
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/23/2005
Last Update Date : 07/08/2007

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