Healthcare Provider Details

I. General information

NPI: 1023473022
Provider Name (Legal Business Name): LANNY LEROY ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2015
Last Update Date: 12/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 N 2ND ST
ATCHISON KS
66002-1402
US

IV. Provider business mailing address

1020 N 2ND ST
ATCHISON KS
66002-1402
US

V. Phone/Fax

Practice location:
  • Phone: 913-360-7541
  • Fax:
Mailing address:
  • Phone: 913-360-7541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number24-00083
License Number StateKS

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: