Healthcare Provider Details

I. General information

NPI: 1164035242
Provider Name (Legal Business Name): AUDREY YAGER LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2020
Last Update Date: 08/28/2020
Certification Date: 08/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 E TRAVIS ST
LULING TX
78648-2900
US

IV. Provider business mailing address

218 E TRAVIS ST
LULING TX
78648-2900
US

V. Phone/Fax

Practice location:
  • Phone: 830-875-2458
  • Fax:
Mailing address:
  • Phone: 830-875-2458
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT6965
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: