Healthcare Provider Details

I. General information

NPI: 1205225828
Provider Name (Legal Business Name): JEFFREY WALTER LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2015
Last Update Date: 08/13/2020
Certification Date: 08/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8700 W WATERTOWN PLANK RD
MILWAUKEE WI
53226-3595
US

IV. Provider business mailing address

1180 FAIRLANE AVE
BROOKFIELD WI
53005-7004
US

V. Phone/Fax

Practice location:
  • Phone: 414-805-7111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1048-39
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: