Healthcare Provider Details

I. General information

NPI: 1205824943
Provider Name (Legal Business Name): JOHN MIKE DAWSON LAT,ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1432 S COLLEGE RD
LAFAYETTE LA
70503-2912
US

IV. Provider business mailing address

401 COURTNEY DR
DUSON LA
70529-4417
US

V. Phone/Fax

Practice location:
  • Phone: 337-232-7080
  • Fax:
Mailing address:
  • Phone: 337-406-2782
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberATH.J00204
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: