Healthcare Provider Details

I. General information

NPI: 1184332017
Provider Name (Legal Business Name): JASON KONECHNE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2022
Last Update Date: 11/09/2022
Certification Date: 11/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4629 E RYAN PKWY
BELOIT WI
53511-4109
US

IV. Provider business mailing address

4629 E RYAN PKWY
BELOIT WI
53511-4109
US

V. Phone/Fax

Practice location:
  • Phone: 716-572-5629
  • Fax:
Mailing address:
  • Phone: 716-572-5629
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1127-039
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: