Healthcare Provider Details

I. General information

NPI: 1356337513
Provider Name (Legal Business Name): JOSHUA PAUL COOPER ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

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

3100 S KINNEY COULEE RD GUNDERSEN LUTHERAN SPORTS MEDICINE
ONALASKA WI
54650-8512
US

IV. Provider business mailing address

2128 PROSPECT ST
LA CROSSE WI
54603-2067
US

V. Phone/Fax

Practice location:
  • Phone: 608-775-8600
  • Fax: 608-775-8614
Mailing address:
  • Phone: 608-779-5625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number498-039
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: