Healthcare Provider Details

I. General information

NPI: 1255804068
Provider Name (Legal Business Name): MEGAN E MEZERA LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MEGAN LECLAIR

II. Dates (important events)

Enumeration Date: 01/03/2019
Last Update Date: 10/30/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 E LINCOLN AVE
LANCASTER WI
53813-2019
US

IV. Provider business mailing address

429 E CHERRY ST
LANCASTER WI
53813-1716
US

V. Phone/Fax

Practice location:
  • Phone: 608-723-3100
  • Fax:
Mailing address:
  • Phone: 920-493-5632
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2349-39
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: