Healthcare Provider Details

I. General information

NPI: 1861883316
Provider Name (Legal Business Name): REBECCA OSZMAN LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: REBECCA ANDERSON

II. Dates (important events)

Enumeration Date: 02/05/2015
Last Update Date: 02/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1531 S MADISON ST
APPLETON WI
54915-1800
US

IV. Provider business mailing address

1531 S MADISON ST
APPLETON WI
54915-1800
US

V. Phone/Fax

Practice location:
  • Phone: 608-566-9842
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1259-039
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: