Healthcare Provider Details

I. General information

NPI: 1174512461
Provider Name (Legal Business Name): JOHN J JOHNSEN LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/19/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 ALGOMA BLVD
OSHKOSH WI
54901-3551
US

IV. Provider business mailing address

1570 MIDWAY PL
MENASHA WI
54952-1165
US

V. Phone/Fax

Practice location:
  • Phone: 920-424-3225
  • Fax:
Mailing address:
  • Phone: 920-720-1784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number4939
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: