Healthcare Provider Details

I. General information

NPI: 1366438335
Provider Name (Legal Business Name): MONICA ANN WAGNER LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 COMMANCHE AVE
GREEN BAY WI
54313-5753
US

IV. Provider business mailing address

8069 COUNTY ROAD A
LENA WI
54139-9737
US

V. Phone/Fax

Practice location:
  • Phone: 920-430-4750
  • Fax: 920-430-4746
Mailing address:
  • Phone: 920-842-3280
  • Fax: 920-430-4746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number345039
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: