Healthcare Provider Details

I. General information

NPI: 1730174749
Provider Name (Legal Business Name): SHELDON ERIC WAGNER ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 SOUTH AVE
LA CROSSE WI
54601-5467
US

IV. Provider business mailing address

455 19TH ST S
LA CROSSE WI
54601-5068
US

V. Phone/Fax

Practice location:
  • Phone: 608-782-7300
  • Fax: 608-775-8614
Mailing address:
  • Phone: 608-796-0111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number252-039
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1270
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: