Healthcare Provider Details

I. General information

NPI: 1902514151
Provider Name (Legal Business Name): LOGAN STEVEN RUPNOW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2022
Last Update Date: 11/07/2022
Certification Date: 11/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 W MARK ST
WINONA MN
55987-3384
US

IV. Provider business mailing address

2405 TUMBLEWEED AVE
WEST BEND WI
53095-8554
US

V. Phone/Fax

Practice location:
  • Phone: 507-457-5575
  • Fax:
Mailing address:
  • Phone: 262-305-4309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: