Healthcare Provider Details

I. General information

NPI: 1366185332
Provider Name (Legal Business Name): MAJA WILSON LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2022
Last Update Date: 10/02/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 BANDANA BLVD E
SAINT PAUL MN
55108-5113
US

IV. Provider business mailing address

1160 CUSHING CIR APT 226
SAINT PAUL MN
55108-5011
US

V. Phone/Fax

Practice location:
  • Phone: 651-241-9700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number3714
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: