Healthcare Provider Details

I. General information

NPI: 1295551240
Provider Name (Legal Business Name): KONNOR GERALD KINGSMORE LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2024
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N91W15750 FALLS PKWY
MENOMONEE FALLS WI
53051-2301
US

IV. Provider business mailing address

W64N14273 WASHINGTON AVE APT 129
CEDARBURG WI
53012-3035
US

V. Phone/Fax

Practice location:
  • Phone: 262-532-1100
  • Fax:
Mailing address:
  • Phone: 719-510-5126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number3219-39
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: