Healthcare Provider Details

I. General information

NPI: 1942831086
Provider Name (Legal Business Name): GREGORY Q SCHULTZ LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2020
Last Update Date: 01/28/2020
Certification Date: 01/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1531 S MADISON ST FL 4
APPLETON WI
54915-1800
US

IV. Provider business mailing address

N470 MAPLERIDGE DR
APPLETON WI
54915-8753
US

V. Phone/Fax

Practice location:
  • Phone: 920-840-0552
  • Fax:
Mailing address:
  • Phone: 920-840-0552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number2139-39
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: