Healthcare Provider Details

I. General information

NPI: 1851804041
Provider Name (Legal Business Name): THOMAS KENNETH KSIAZEK MSAT, LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 S COTTONWOOD ST
NORTH PLATTE NE
69101-6108
US

IV. Provider business mailing address

816 S YORK AVE
NORTH PLATTE NE
69101-6279
US

V. Phone/Fax

Practice location:
  • Phone: 308-568-7456
  • Fax:
Mailing address:
  • Phone: 402-276-6590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number854
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: